Medicare Advantage appeals

A Medicare Advantage plan is a private plan that provides your Medicare benefits. When it refuses to cover or pay for something, you appeal to the plan first. If the plan does not change its mind, an outside reviewer looks at your case, and you do not have to ask for that step. The reference page is Medicare Advantage (Part C).

What this means

The plan’s first decision is called an organization determination. It includes a refusal to provide or pay for a service, a cut or early end to care the plan had approved, and a failure to answer in time. All of these can be appealed.

The plan’s appeal is called a reconsideration. A doctor or other professional with the right expertise must review a denial based on medical necessity, and the person who reconsiders it must not have been involved in the first denial.

Medicare Advantage plans must follow Original Medicare’s coverage rules. They may write their own criteria only where Medicare’s are not fully established, and they must post those criteria publicly with the evidence behind them. Medical necessity decisions must take into account your own medical history, your doctor’s recommendations and clinical notes. That is something to point to in your appeal.

How fast the plan must decide

These are the verified federal timeframes. The plan’s denial notice should state the ones that apply to you.

• First decision, standard. 14 calendar days. For items and services that need prior authorization, 7 calendar days starting 1 January 2026. The plan may extend by up to 14 calendar days in limited cases and must tell you in writing.
• First decision, fast. 72 hours, when your doctor says, or the plan finds, that waiting could seriously jeopardize your life, health or ability to regain maximum function.
• Part B drugs (drugs given in a doctor’s office or outpatient setting): 72 hours standard and 24 hours fast, with no extension.
• Reconsideration decision. 30 calendar days before care, 60 calendar days for payment, 7 calendar days for a Part B drug, and 72 hours when fast.

The 7-day rule does not apply to drugs, and it does not apply to employer plans or to Marketplace plans on the federal exchange. Plans must now also give a specific reason for a prior authorization denial.

What to do

1. Read the denial notice (you). It should be on a standard form. Find the date and the reason.
2. Ask your doctor to support the appeal (your doctor). A treating physician can ask on your behalf after telling you. If waiting could harm you, your doctor can say so, and the plan must then give a fast decision. If the plan refuses to speed it up, you can file an expedited grievance about that.
3. File the reconsideration (you or your doctor). A standard request should be in writing unless the plan accepts oral requests. A fast request can be made orally. The deadline is 65 days from the date on the notice. The rule states it as 60 days after receipt, with receipt presumed 5 days after the notice date.
4. Ask for the file and send your evidence (you). Attach a letter from your doctor and your records.
5. Wait for the outside review (nothing to file). If the plan upholds its denial in whole or in part, or misses its deadline, it must send the case to the Independent Review Entity under contract with the Centers for Medicare & Medicaid Services (CMS). For fast cases the file must go within 24 hours. Since 1 May 2026, that entity is C2C Innovative Solutions, Inc.
6. Know the exception (you). If the plan dismisses your request, for example as late or invalid, you must ask the outside reviewer in writing to review the dismissal within 60 days of the dismissal notice. CMS describes this as 65 days from the notice date.
7. Go further if you lose (you). The later levels match Original Medicare: a judge at 60 days with at least $200 in dispute in 2026, then the Council, then court at $1,960 in 2026 ($2,000 from 1 January 2027). See Original Medicare: the five appeal levels.

The rule

A request for reconsideration must be filed within 60 calendar days after you receive the notice, and receipt is presumed to be 5 calendar days after the date on the notice. (Title 42 of the Code of Federal Regulations (CFR), section 422.582(b))

Check the date on your notice, which controls.

What the plan may say, and what to say back

“Prior authorization was approved, but we are now denying payment.”

Once a plan approves a service through prior authorization or another pre-service decision, it may not later deny coverage for lack of medical necessity. It may reopen the approval only for good cause or reliable evidence of fraud or similar fault.

Watch for

• What this site has not verified. The first date the 65-day wording applied to plans, generally described as 1 January 2025, is not confirmed. The 2027 contract-year rule appears to have left appeal deadlines unchanged, but that was checked by a text search, not a full read.
• Few people appeal. KFF, a health policy research organization formerly named the Kaiser Family Foundation, analyzed 2024 plan-reported data and found that Medicare Advantage insurers fully or partly denied 7.7 percent of about 52.8 million prior authorization determinations. People appealed 11.5 percent of the denials, and 80.7 percent of the appeals were partly or fully overturned. That does not predict your outcome.
• A grievance is not an appeal. A complaint about rudeness or waiting times is a grievance, filed within 60 days of the event.
• Treatment already under way. A new member in the middle of treatment gets at least a 90-day transition period in which the plan may not disrupt that treatment.
• A paid claim from your own provider. If an in-network provider’s payment was decided and you owe nothing further, the member appeal process does not apply to it.

What next

• Medicare fast appeals cover a hospital discharge or care that is ending, which use a different, faster route.
• Free Medicare counseling connects you with a State Health Insurance Assistance Program counselor.
• Medicare, Medicare Advantage and drug plans lists every Medicare page.