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Web learn how to request an appeal (redetermination, reconsideration, or hearing) if you disagree with medicare’s coverage. Web use this form to appeal a decision on your disability or other benefits if you do not agree with it. Web medicare reconsideration request form — 2nd level of appeal. You can request an appeal online. Date of the redetermination notice (mm/dd/yyyy). Web request medical reconsideration continue request for medical reconsideration you started.