Medicare Advantage Denied Your Care? What to Do (2026)

Your Medicare Advantage plan denied care your doctor ordered, and the letter reads like the end of the road. It is not. When beneficiaries and providers appealed during 2014 through 2016, Medicare Advantage plans overturned 75% of their own denials, roughly 216,000 a year, and yet only 1% of denials were ever appealed at all.1 For a Medicare Advantage denial you generally have 65 days from the date on the plan's notice to file that appeal.2

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. When it decides whether care is medically necessary, it must apply Medicare's coverage criteria. It may fall back on internal coverage criteria of its own only in narrow situations, such as where Medicare's criteria are not available, are not detailed enough to make consistent decisions, or include flexibility that allows coverage in circumstances the criteria do not spell out.1

The company still gets to manage how you reach 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.

Denials are not the norm. Plans approve the vast majority of requests for services and payment. But they issue millions of denials each year, and when the HHS Office of Inspector General, the federal watchdog for Medicare, examined a sample of them, it found two common causes on the prior authorization side: plans applying clinical criteria not contained in Medicare's coverage rules, such as requiring an x-ray before approving more advanced imaging, and plans asking for more documentation when OIG's own physician reviewers found the existing medical records already sufficient. Most of the denied payment requests came down to human error during manual claims processing and to system processing errors.1

So a denial can mean the care truly isn't covered. Or it can mean your plan applied a criterion of its own. From the letter you get in the mail, you often can't tell which, and OIG itself said CMS guidance was not detailed enough to determine whether plans may deny authorization based on internal criteria that go beyond Medicare's coverage rules.1 What you can do is ask. Since 2024, CMS has required Medicare Advantage organizations to make their internal coverage criteria publicly accessible, so you can ask your plan for the criterion it used.1

What Auditors Found When They Checked Medicare Advantage Denials

This isn't a hunch. In report OEI-09-18-00260, published in April 2022, the HHS Office of Inspector General took a stratified random sample of 250 prior authorization denials and 250 payment denials issued by 15 of the largest Medicare Advantage organizations during a single week, June 1 through 7, 2019, and read each one against Medicare's actual coverage rules.1

Two numbers stand out. Among the prior authorization requests those plans denied, 13% met Medicare's coverage rules, meaning the services likely would have been approved for those beneficiaries under Original Medicare. Among the payment requests they denied, 18% met both Medicare's coverage rules and the plan's own billing rules.1

Read those figures for what they are: findings from a sample of denials drawn over one week in 2019, not a running national denial rate, and OIG was careful to say up front that plans approve the vast majority of what is asked of them.1 Even so, behind each percentage is a real person told no for care that met Medicare's rules. The services OIG named as examples are the ones families run into most: advanced imaging such as MRIs, and post-acute facility stays such as inpatient rehabilitation.1

Most Appealed Denials Get Overturned

This is the finding that should change how you react to a denial letter. In an earlier report, OEI-09-16-00410, the HHS Office of Inspector General looked at what happened during 2014 through 2016 when beneficiaries and providers actually appealed. Medicare Advantage plans overturned 75% of their own denials, about 216,000 reversals every year, and independent reviewers at higher levels of the appeals process overturned additional denials in favor of beneficiaries and providers.1

That tells you the initial denial is often a first answer, not a final one.

The auditors flagged a frustrating flip side. Over those same years, beneficiaries and providers appealed only 1% of denials to the first level of appeal, a process OIG described as one they rarely used.1 So the overwhelming majority of denials were never challenged at all. All that care that would have been overturned on appeal? For nearly everyone, the appeal never got filed, and the no just stood.

A denial you don't appeal is a denial the plan gets to keep, even when the plan itself would have reversed it.

A formal appeal is also not the only thing that works. OIG found that reversals often followed a beneficiary or provider appealing or simply disputing the denial, and that in some cases the plan identified its own error.1 Calling the plan and asking it to look again is worth doing, but do it with the clock running: your 65 days start from the date on the notice, not from the day the phone call ends.2

How to Appeal Medicare Advantage Denied Care

Appealing is a real, defined process, and you have the right to use it. Start with the denial notice, but don't assume the notice tells you everything. In 2015, CMS cited 45% of audited contracts for sending denial letters with incomplete or incorrect information, which may inhibit a beneficiary's ability to file a successful appeal, and cited 56% of audited contracts for making inappropriate denials in the first place.1 If your letter doesn't give a specific reason or explain how to challenge it, that is the plan's failing, not yours. Call and ask.

1. Find the reason, in writing. Ask the plan to explain the specific rule it applied. If it's a clinical criterion, ask whether it's Medicare's or the plan's own, and if it's the plan's own, ask for a copy of the criterion.1
2. 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.
3. File within 65 days. A Medicare Advantage plan-level appeal, formally a reconsideration of the organization determination, must be filed within 65 days of the date on the plan's initial denial notice, and filing late requires giving a reason. Keep copies of everything you send.2
4. Expect an outside review if the plan says no again. When a Medicare Advantage plan upholds its own denial, it must automatically forward the case to an Independent Review Entity, an outside organization that is not your plan. Above that sit three further levels: an Administrative Law Judge, the Medicare Appeals Council, and federal district court.2

When the care is urgent and waiting could seriously jeopardize your life, your health, or your ability to regain maximum function, you can ask for a fast (expedited) decision instead of the standard timeline. Medicare Advantage plans must offer expedited appeals in those circumstances, and an expedited plan decision is generally issued within 72 hours.2 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.1 Don't let a first no be the last word.

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.