Medicare Advantage Plan Denied Your Claim

What This Means

Your Medicare Advantage (MA) plan — the private insurance company that manages your Medicare benefits — has decided not to pay for a service, treatment, or item. This could be a denial of a prior authorization request (before you get the service) or a claim denial (after you already received the service).

Medicare Advantage plans are required to cover everything Original Medicare covers, but they may apply different rules about how and when services are approved.

Why This Happens

• Prior authorization was required but not obtained. Many MA plans require pre-approval for certain services. If your provider didn’t get approval first, the plan may deny the claim.
• The plan says the service isn’t medically necessary. Your plan reviewed the clinical information and decided the service didn’t meet its coverage criteria. This is the most common reason for MA denials.
• The plan applied clinical criteria stricter than Original Medicare’s rules. A 2022 HHS Office of Inspector General report found that 13% of prior authorization denials involved services that likely would have been approved under Original Medicare.
• You used an out-of-network provider. Most MA plans have provider networks. Services from out-of-network providers may not be covered, except in emergencies.
• Missing or incomplete documentation. The plan may not have received enough medical records to support the request.

Should You Appeal?

What To Do Next

1. Read your denial notice carefully. It must explain why your claim was denied and include instructions for how to appeal. Keep this notice — you’ll need it.
2. Note your deadline. You typically have 65 days from the date on the denial notice to file a first-level appeal (called a “reconsideration”). Don’t wait.
3. Call your doctor’s office. Ask them to provide a supporting statement or letter of medical necessity. Your appeal is stronger with your doctor’s backing.
4. File your appeal with your plan. Follow the instructions on your denial notice. How long the plan has to decide depends on what you are appealing: 30 calendar days for a standard request for a service or item you have not received yet, or 60 calendar days when you are asking the plan to pay for care you already received (42 CFR 422.590). Expedited 72-hour review is available when delay could harm your health, but only for services you have not received yet — 42 CFR 422.584(a) excludes requests for payment of services already furnished.
5. If the plan upholds its denial, your case automatically goes to an Independent Review Entity (IRE) — an outside organization not connected to your plan. This is a key protection in the MA appeals process.
6. Get free help. Contact your State Health Insurance Assistance Program (SHIP) for free, unbiased counseling. You can also call 1-800-MEDICARE (1-800-633-4227).

Understanding the MA Appeal Levels

Levels 1 and 2 run on the same clock, and which figure applies depends on what you asked the plan for: 30 calendar days for a standard request for a service or item you have not received yet, 60 calendar days for a request to pay for care already furnished, and 7 calendar days for a standard Part B drug request. Only the pre-service window can be stretched: 42 CFR 422.590(f) allows up to 14 extra calendar days for a service or item request, the payment window has no extension provision at all, and the Part B drug window expressly cannot be extended. Because the denials that arrive after treatment are payment requests, 60 days is the figure most readers of this page should expect — and it is a hard 60.

The 2026 amount-in-controversy thresholds are set by CMS in the Federal Register: $200 for an Administrative Law Judge hearing (Level 3) and $1,960 for federal district court review (Level 5).

Sources

• KFF: Medicare Advantage Prior Authorization and Denial Data, 2024 — 80.7% of appealed prior-authorization denials overturned; 11.5% of denials appealed (2024 data).
• HHS OIG: Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care (2022) — the finding that 13% of denied prior-authorization requests met Medicare coverage rules.
• Federal Register: CY2026 Medicare Appeals Amount-in-Controversy Thresholds — the $200 (ALJ) and $1,960 (federal court) thresholds for 2026.
• 42 CFR 422.590 — the plan’s reconsideration deadlines: 30 calendar days for a standard request for a service or item, 60 calendar days for a request for payment, 7 calendar days for a standard Part B drug request, and 72 hours when expedited.
• 42 CFR 422.584 — who may request an expedited reconsideration, and its exclusion of requests for payment of services already furnished.
• Medicare.gov: Appeals in Medicare Health Plans — the Medicare Advantage appeal levels, and the same pre-service / payment / Part B drug decision timeframes applied at both Level 1 and the Level 2 IRE review.
• CMS: Reconsideration by Part C Independent Review Entity (IRE) — the Level 2 decision timeframes (72 hours expedited; 30 calendar days standard pre-service; 7 calendar days standard Part B drug; 60 calendar days payment).
• HHS: Level 1 Appeals — Medicare Advantage (Part C) — how the plan reconsideration and automatic IRE forwarding work.

Frequently Asked Questions