How long do I have to appeal a Medicare Advantage denial?

Generally 65 days from the date on the denial notice for a plan reconsideration. Check your notice for the exact date.

How fast must a Medicare Advantage plan decide a fast appeal?

Within 72 hours for a fast (expedited) reconsideration of medical care, when waiting could seriously harm your health.

Do Medicare Advantage plans have to follow Original Medicare rules?

Since 2024, CMS requires MA plans to follow Traditional Medicare coverage criteria, with limited room for their own publicly available, evidence-based criteria.

Who reviews my appeal if the plan says no again?

An Independent Review Entity contracted by Medicare. For medical services the plan must forward your case automatically.

Medicare Advantage Prior Authorization Denial: How to Appeal

By AppealFlow editorial•5 min read•Published October 2026

If your Medicare Advantage plan denies prior authorization, you can ask the plan for a reconsideration, generally within 65 days of the denial notice, and request a fast (72-hour) decision if waiting could seriously harm your health. Since 2024, CMS rules require MA plans to follow Traditional Medicare coverage rules and limit their own criteria, and any denial based on medical necessity must be reviewed by a physician with relevant expertise. If the plan upholds the denial, the case is automatically forwarded to an independent reviewer.

What Are My Medicare Advantage Appeal Levels?

Key Takeaway: The first two levels are the ones most people use.

Level 1: Reconsideration by your plan. Standard pre-service decisions within 30 days; fast decisions within 72 hours.
Level 2: Independent Review Entity (IRE). If the plan upholds its denial for medical services, it must send your case automatically.
Level 3: Administrative Law Judge hearing, if the amount in controversy meets the yearly threshold.
Level 4: Medicare Appeals Council.
Level 5: Federal district court.

What Did CMS Change in 2024?

Key Takeaway: These rules are useful in appeals.

The CY2024 Medicare Advantage final rule (CMS-4201-F) says MA plans must follow Traditional Medicare's national and local coverage determinations and general coverage rules. Where those rules aren't fully set out, plans may use internal criteria only if they're publicly available and based on current evidence. Approved prior authorizations must remain valid for an entire course of treatment, and there's a 90-day transition period for new enrollees in an ongoing course of treatment. Denials based on medical necessity must be reviewed by a physician or other professional with expertise in the relevant field.

How Do I Appeal?

Key Takeaway: Start with the notice and your doctor.

Read the Notice of Denial of Medical Coverage for the reason and the deadline.
Ask your doctor to request the reconsideration; doctors can request fast appeals for you and their support makes it more likely to be granted.
Ask the plan for the criteria used and check whether they match Traditional Medicare's coverage rules (search the Medicare Coverage Database for the relevant NCD or LCD).
Submit records and a letter explaining why the service meets those rules.
Use the prior authorization appeal generator for the letter.
For drugs, the process runs through Part D instead: see Part D prior authorization appeals.

Where Can I Get Free Help?

Key Takeaway: Every state has a counseling program.

Your State Health Insurance Assistance Program (SHIP) gives free one-on-one Medicare counseling, including appeals. You can also call 1-800-MEDICARE. During open enrollment (October 15 to December 7) and the Medicare Advantage open enrollment period (January 1 to March 31), you can change plans if repeated denials are a problem.

Related Guides

Frequently Asked Questions

Sources

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Disclaimer: This article is for educational purposes only and does not constitute medical, legal, or financial advice. Plan terms, state laws, and federal rules vary and change. Check your plan documents and denial notice, and consider a licensed professional or your state consumer assistance program. See our full disclaimer.