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Medicare Advantage Denied Your Care? How the Appeal Works

Two hands holding a blank white card over a dark wooden table, with a sticky note reading “65 days”.
Photo by Megan Watson on Unsplash

The letter says the care your doctor asked for won't be covered, or that a bill you already ran up won't be paid. It reads like a final answer. It isn't. It's the plan's first decision, and a 65-day window to push back opens on the date printed on it. Whether the plan gets weeks or hours to answer can turn on one sentence from your doctor's office. Most denials are never appealed at all.

See what to send with your appeal

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By Margaret Linwood · Updated Oct 15, 2026 · Reviewed against Medicare.gov, CMS, KFF, HHS-OIG, 42 CFR 422

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Not every no works the same way. A denial before you've had the care runs on a different clock than a bill the plan won't pay, and a hospital discharge or a drug denial each has a track of its own. The notice tells you which one you're on.

Since January 2026, every denial has to give a specific reason. That one line matters more than the rest of the page. Some reversals happen simply because the first request was missing paperwork the plan wanted, and paperwork is exactly what you and the doctor's office can fix the second time around.

See the rules your plan has to follow

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Rules your plan has to follow

Plans write the denial letters, but they don't write all the rules. Four federal requirements for Medicare Advantage are worth knowing before you put an appeal together.

  1. Original Medicare's coverage rules. A plan has to cover what Original Medicare covers, and it can't deny basic benefits using criteria that aren't in those national rules or in its own published policies.
  2. A qualified reviewer. When a denial says the care isn't medically necessary, a physician or another health professional with the right expertise had to review it before the letter went out.
  3. Approvals that stick. Once a plan signs off on a service in advance, it can't later deny coverage for lack of medical necessity, except for good cause or reliable evidence of fraud. That's why every approval letter is worth keeping.
  4. A transition period. Someone who joins a new plan in the middle of an active course of treatment gets at least 90 days of transition, even with an out-of-network provider.

Rules help most when they're in the file from day one. The article covers the deadlines, the fast track and what to send with that first appeal.

See all five appeal levels in one table

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