WASHINGTON – A Medicare claim must be worth at least $200 next year before an administrative law judge will hear an appeal of it.
CMS published the figure on 16 September 2026. The notice says the amounts apply to requests “filed on or after January 1, 2027.”
There is a second line above it. To take a Medicare case to judicial review, the amount still in dispute must be at least $2,000.
Neither line is about whether you are right. Each is about whether the money left in dispute is large enough to buy a hearing.
What the two numbers gate#
The hearing before an administrative law judge is the third level of Medicare’s appeal process. CMS names it that way on its own appeals page.
You reach it after a contractor has already reconsidered the claim and said no.
CMS says the request must be filed within 60 days of receiving that decision. It treats the decision as received five days after its date, unless there is evidence otherwise.
There is one route that does not wait. If the contractor misses its deadline, CMS says the appealing party may escalate to a judge or an attorney adjudicator.
AIC stands for amount in controversy. CMS calls it the amount remaining in controversy, and it sets out the arithmetic.
You start with what you were charged. You subtract anything Medicare has already paid. You subtract any deductible or coinsurance.
CMS gives a worked example. A $500 charge, nothing paid by Medicare, a $100 copayment, leaves $400.
The threshold is not only for traditional Medicare. The notice as published reports that the adjustment reaches Medicare Advantage appeals. It reaches certain health maintenance organization and competitive medical plan appeals. And it reaches health care prepayment plans.
It has its own section for Part D, which says the same amounts “also apply to Medicare Part D appeals.”
So a refused drug meets the same $200 line as a refused procedure.
Where $200 came from#
Congress set these lines in statute. The notice describes that section in its own words.
“established the amount in controversy (AIC) threshold amounts for Administrative Law Judge (ALJ) hearings and judicial review at $100 and $1,000, respectively …”
That sentence does not end there. It ends “for Medicare Part A and Part B appeals.”
Beginning in January 2005 those amounts are “adjusted annually” by a method the statute fixes.
They rise with the “percentage increase in the medical care component of the consumer price index” for all urban consumers. The measure runs from July 2003 to the July before the year in question. The result is rounded to the nearest $10.
The base month is July 2003, so the comparison never resets to a later year.
The notice shows its arithmetic. The index rose 99.523 percent, which puts the judge threshold at $199.52 before rounding. The index ran from 297.600 to 593.781.
The notice also prints the series, 2023 through 2027. The judge line ran 180, 180, 190, 200 and 200. The court line ran 1,850, 1,840, 1,900, 1,960 and 2,000.
One of those is not a rise. The court threshold fell by $10 between 2023 and 2024. The notice prints that decrease in its own table and explains it nowhere.
Across two decades both statutory lines have doubled. The $100 Congress wrote is now $200. The $1,000 is now $2,000.
What it does not say, and what happens next#
It does not say how many appeals fall below the line each year. That count is not in the document, and this page will not estimate one.
It does not say whether several small refusals can be added together to clear the threshold. The notice and the CMS appeals page were both searched for aggregating, combining and consolidating claims. Neither carries any of it.
That silence matters to anyone holding three small refusals. The answer may sit elsewhere in Medicare’s appeal regulations. Neither document carries it, and a page implying otherwise would be inventing the comfort.
The notice gives no hardship exception. A search of its full text returns nothing on hardship, and nothing on transition relief for requests already in progress.
Nothing here is open for comment. The word does not appear in the notice. The adjustment is arithmetic the statute requires, not a policy anyone is choosing.
The statute requires this adjustment every year, so a notice setting the 2028 amounts is due. Its date and its figures are not yet public, and this page will not guess either.
For anyone appealing now, three things hold. The amount that counts is what remains in dispute. The date that decides which figure applies is the date the request is filed. And reaching the judge is not the same as winning.
Related: when a machine decides and AI is deciding Medicare coverage.
Source: Federal Register notice 2026-19016, published 16 September 2026, full text read; and CMS’s Third Level of Appeal page, read 18 September 2026.