Your Medicare Advantage plan denied care your doctor ordered, but federal auditors found plans reverse 75% of the denials people actually appeal. A denial from your plan is not the final word, and appealing it works far more often than most people expect.oig.hhs.gov. (2022). HHS-OIG OEI-09-18-00260 — Some MAO Denials of Prior Authorization Requests Raise Concerns (2022). Retrieved Jul 10, 2026, from https://oig.hhs.gov/reports/all/2022/some-medicare-advantage-organization-denials-of-prior-authorization-requests-raise-concerns-about-beneficiary-access-to-medically-necessary-care/
Why Your Medicare Advantage Plan Denied Care Original Medicare Covers
A Medicare Advantage plan is run by a private insurance company, not by the government. By law it has to cover everything Original Medicare covers. But the company gets to manage how you get that care, and one of its main tools is prior authorization, the approval you or your doctor have to get before the plan agrees to pay.
That approval step is where denials happen. And they don't always happen because the care isn't covered. When the HHS Office of Inspector General, the federal watchdog for Medicare, dug into why plans were saying no, it found that denials were often driven by the plan applying its own clinical criteria that aren't part of Medicare's coverage rules, by the plan asking for extra documentation it didn't really need, and by plain human and system processing errors.oig.hhs.gov. (2022). HHS-OIG OEI-09-18-00260 — Some MAO Denials of Prior Authorization Requests Raise Concerns (2022). Retrieved Jul 10, 2026, from https://oig.hhs.gov/reports/all/2022/some-medicare-advantage-organization-denials-of-prior-authorization-requests-raise-concerns-about-beneficiary-access-to-medically-necessary-care/
So a denial can mean the care truly isn't covered. Or it can mean your plan added a hurdle that Medicare itself never requires. From the letter you get in the mail, you often can't tell which. That's exactly why it pays to push back.
What Auditors Found When They Checked Medicare Advantage Denials
This isn't a hunch. The HHS Office of Inspector General pulled a random sample of denials from June 2019 across 15 of the largest Medicare Advantage organizations and read each one against Medicare's actual coverage rules.
Two numbers stand out. Among the requests for care that plans denied through prior authorization, 13% met Medicare's coverage rules, meaning that care likely would have been approved under Original Medicare. Among the requests for payment that plans denied, 18% met both Medicare's coverage rules and the plan's own billing rules.oig.hhs.gov. (2022). HHS-OIG OEI-09-18-00260 — Some MAO Denials of Prior Authorization Requests Raise Concerns (2022). Retrieved Jul 10, 2026, from https://oig.hhs.gov/reports/all/2022/some-medicare-advantage-organization-denials-of-prior-authorization-requests-raise-concerns-about-beneficiary-access-to-medically-necessary-care/
Think about what that means for a real family. Roughly one in eight denied prior authorization requests, and nearly one in five denied payment requests, were care the government says should have been covered. Behind each of those percentages is someone who was told no for a service they were entitled to.
Most Appealed Denials Get Overturned
This is the finding that should change how you react to a denial letter. In an earlier review covering 2014 through 2016, the HHS Office of Inspector General looked at what happened when patients and their doctors actually appealed. Medicare Advantage plans overturned 75% of their own denials, about 216,000 reversals every year.oig.hhs.gov. (2022). HHS-OIG OEI-09-18-00260 — Some MAO Denials of Prior Authorization Requests Raise Concerns (2022). Retrieved Jul 10, 2026, from https://oig.hhs.gov/reports/all/2022/some-medicare-advantage-organization-denials-of-prior-authorization-requests-raise-concerns-about-beneficiary-access-to-medically-necessary-care/
That's a striking rate, and it tells you the initial denial is often a first answer, not a final one.
The auditors also flagged a frustrating flip side: patients and providers appealed only a small share of the denials they received. So the great majority of denials were never challenged at all. All that care that would have been overturned on appeal? For most people, the appeal never got filed, and the no just stood.oig.hhs.gov. (2022). HHS-OIG OEI-09-18-00260 — Some MAO Denials of Prior Authorization Requests Raise Concerns (2022). Retrieved Jul 10, 2026, from https://oig.hhs.gov/reports/all/2022/some-medicare-advantage-organization-denials-of-prior-authorization-requests-raise-concerns-about-beneficiary-access-to-medically-necessary-care/
A denial you don't appeal is a denial the plan gets to keep, even when the plan itself would have reversed it.
How to Appeal Medicare Advantage Denied Care
The good news is that appealing is a real, defined process, and you have the right to use it. Your plan is required to tell you, in writing, why it denied the request and how to challenge that decision. Start there:
- Read the denial notice and find the reason. Call the plan and ask them to explain the specific rule they applied. If the reason is a clinical criterion, ask whether it's Medicare's rule or the plan's own.
- Get your doctor involved. A letter from the ordering physician explaining why the care is medically necessary carries real weight, and your doctor's office can file the appeal with you.
- File the appeal before the deadline in your notice, and keep copies of everything you send.
- If your plan says no again, the appeal moves to an independent reviewer outside the plan, and there are further levels above that.
When the care is urgent and waiting could harm your health, you can ask for a fast (expedited) decision instead of the standard timeline. Brevy's guide to a Medicare fast appeal walks through when you qualify and how to request one, and our full Medicare appeals guide lays out every level in order.
Because most appealed denials are overturned, the effort is usually worth it.oig.hhs.gov. (2022). HHS-OIG OEI-09-18-00260 — Some MAO Denials of Prior Authorization Requests Raise Concerns (2022). Retrieved Jul 10, 2026, from https://oig.hhs.gov/reports/all/2022/some-medicare-advantage-organization-denials-of-prior-authorization-requests-raise-concerns-about-beneficiary-access-to-medically-necessary-care/ Don't let a first no be the last word.
Frequently Asked Questions
Can a Medicare Advantage plan really deny care that Medicare covers?
Yes. A Medicare Advantage plan must cover what Original Medicare covers, but it manages access through prior authorization and can deny a request anyway. Federal auditors found that 13% of denied prior authorization requests actually met Medicare's coverage rules and would likely have been approved under Original Medicare.oig.hhs.gov. (2022). HHS-OIG OEI-09-18-00260 — Some MAO Denials of Prior Authorization Requests Raise Concerns (2022). Retrieved Jul 10, 2026, from https://oig.hhs.gov/reports/all/2022/some-medicare-advantage-organization-denials-of-prior-authorization-requests-raise-concerns-about-beneficiary-access-to-medically-necessary-care/
How often do Medicare Advantage plans overturn their own denials?
Often. In a review of 2014 through 2016 denials, plans overturned 75% of the denials that were appealed, about 216,000 a year.oig.hhs.gov. (2022). HHS-OIG OEI-09-18-00260 — Some MAO Denials of Prior Authorization Requests Raise Concerns (2022). Retrieved Jul 10, 2026, from https://oig.hhs.gov/reports/all/2022/some-medicare-advantage-organization-denials-of-prior-authorization-requests-raise-concerns-about-beneficiary-access-to-medically-necessary-care/ The initial denial is frequently not the final answer, which is a strong reason to appeal.
Why did my Medicare Advantage plan deny care my doctor said I need?
The federal watchdog found denials were commonly caused by the plan using its own clinical criteria that aren't in Medicare's rules, by requests for extra documentation, and by processing errors. Ask your plan for the specific reason in writing so you know what you're appealing.
Is it worth appealing a Medicare Advantage denial?
Usually, yes. Most denials that get appealed are overturned, but only a small share of denials are ever challenged. If you appeal and the plan won't reverse itself, an independent reviewer outside the plan takes a fresh look.
What if I need the care urgently?
You can request a fast, or expedited, decision when waiting for the standard timeline could seriously harm your health. Ask your plan for an expedited appeal, and have your doctor support the request.
Learn More
Find personalized help appealing a Medicare Advantage denial at brevy.com.
The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.