Medicare Advantage Prior Authorization Denials: What to File

The denial letter from a Medicare Advantage plan tells you to appeal within 65 days. The federal regulation that letter is written under says 60. Neither is a typo. The regulation counts 60 calendar days from when you receive the notice and then presumes you received it five days after the date printed at the top (42 CFR 422.582(b)). The standard notice does the addition for you. If the letter is dated 2 March, both routes land on 6 May, and the plan has to have your request in hand by then, because the filing date is the day the plan receives it, not the day you post it.

Prior authorization in Medicare Advantage runs on clocks that were partly rewritten for 2026, and most of what you find when you search the subject was written for the provider's authorization desk. This page is for the enrollee holding the denial. The regulations quoted are the eCFR text as of 15 September 2026 and the CMS pages were read on 19 September 2026; each number has its source beside it, and it is worth checking because several of these rules changed this year. This is not legal advice.

What your plan actually decided when it said no

In Medicare Advantage language, the denial is an organization determination. The definition is broad: it covers the plan's refusal "pre- or post-service or in connection with a decision made concurrently with an enrollee's receipt of services, to provide or pay for services, in whole or in part, including the type or level of services," and also a reduction or early stop of a course of treatment the plan had already authorized (42 CFR 422.566(b)(3)–(4)).

"In part" counts: if you asked for twelve physical therapy visits and the plan approved six, the six that were cut carry full appeal rights. The word concurrently came in with the contract year 2026 rule, CMS-4208-F (90 FR 15792), so a decision made while you are already in the hospital, such as treating your stay as outpatient observation rather than an inpatient admission, is an organization determination with notice and appeal rights, not a matter only between the plan and the hospital.

A standard request can come from you, your representative, or any provider that furnishes or intends to furnish the service; an expedited one from you, your representative, or any physician, in network or not (422.566(c)). When the doctor's office sent the request, the plan notifies the office as well as you (422.568(b)(1)), so the office may hear first.

The notice has a standard shape

CMS requires a standardized notice, the Notice of Denial of Medical Coverage (or Payment), Form CMS-10003-NDMCP, also called the Integrated Denial Notice (CMS, Managed Care Notices and Forms). If your letter does not look like that form, keep it anyway and note the difference.

The template has a blank headed Why was coverage denied?, and the instruction printed in it tells the plan to "Provide specific rationale for decision and include State or Federal law and/or Evidence of Coverage provisions to support decision." The rest of the form is boilerplate. That one paragraph is the only part written about you, and it is what your appeal answers.

The plan's clock before it decides

These are the limits for a service or item you have not received yet.

The 7-day line came from the Interoperability and Prior Authorization final rule, CMS-0057-F (89 FR 8758); before 2026 every standard request had 14 days. Days are calendar days from when the plan receives the request, weekends included: received Monday 14 September, due Monday 21 September.

Extensions are allowed, and they are yours to contest

The plan can stretch a standard or expedited service decision by up to 14 calendar days in three situations: you ask for more time, it needs records from an out-of-network provider that might change a denial, or "extraordinary, exigent, or other non-routine circumstances" make the extension in your interest (422.568(b)(2)(i)). When it does, it owes you a written explanation and must tell you that you can file an expedited grievance if you disagree. A grievance about an extension has to be answered within 24 hours (42 CFR 422.564(f)). It will not make the plan decide faster by itself, but it puts the reason for the delay on paper.

Silence is a denial you can appeal

If the plan does not send notice in time, "this failure itself constitutes an adverse organization determination and may be appealed" (422.568(f); the expedited version is 422.572(f)). If day 7 has passed with nothing, you can file a reconsideration on that basis, stating the date the request went in and the date it was due.

Getting the 72-hour track

An expedited decision is available when waiting the standard time "could seriously jeopardize the life or health of the enrollee or the enrollee's ability to regain maximum function" (42 CFR 422.570(c)(2)). The rule treats requests differently depending on who makes them. If you ask on your own, the plan decides whether you qualify. If a physician makes the request or supports yours and indicates that the standard timeframe could cause that harm, the plan must expedite. A call or a one-line fax from any physician turns a request the plan may refuse to expedite into one it has to.

If the plan turns down an expedited request, it moves it to the standard track, counting from the day it received the expedited request, and within 3 calendar days sends you a letter saying you can resubmit with a physician's support (422.570(d)). One wrinkle if you read the regulation yourself: the current text of 422.570(d)(2)(i) still says that letter explains "the 14-day timeframe for standard determinations." Paragraph (d)(1) of the same section sends the transferred request to "the applicable timeframe, established in § 422.568," and 422.568 gives 7 days for an item under the plan's prior authorization rules, so our reading is that the 7-day limit applies and the 14-day phrase in the letter requirement was not revised. If your letter quotes 14 days for such an item, ask the plan in writing which paragraph of 422.568 it is relying on.

Payment requests, where you already had the service, cannot be expedited at all (422.570(a)).

What the denial has to tell you, and who had to look at it

The notice must "state the specific reasons for the denial," tell you about your right to a reconsideration, and for a service denial describe both the standard and the expedited appeal processes (422.568(e)). From 1 January 2026 the response the plan sends the provider on a denied prior authorization request (drugs are excluded) must include "a specific reason for the denial, regardless of the method used to communicate that information" (42 CFR 422.122(a)). Ask your doctor's office for a copy of what they received; it can be more specific than your letter.

If the plan expects to deny, even partly, on medical necessity grounds, the case has to be reviewed first by "a physician or other appropriate health care professional with expertise in the field of medicine or health care that is appropriate for the services at issue, including knowledge of Medicare coverage criteria," holding a current, unrestricted license (422.566(d)). The reviewer need not share your doctor's specialty, but if the letter does not say who reviewed the request, ask.

Why "not medically necessary" is a checkable claim in Medicare Advantage

Private insurers write their own medical policies. Medicare Advantage plans have much less room. Prior authorization may be used only to confirm diagnoses or other medical criteria, to check that a basic benefit is medically necessary, or to check that a supplemental benefit is clinically appropriate (42 CFR 422.138(b)). Where Original Medicare already has a coverage rule, in statute, regulation, or a national or local coverage determination, the plan must follow it, and it may write internal criteria only where those rules are "not fully established," publishing them when it does (42 CFR 422.101(b)(6); see finding the criteria behind a medical necessity denial). So the first question about an MA denial is whether Original Medicare would have covered the same thing for the same diagnosis. If it would, the plan's reason has to explain why you are different. Each policy must also be reviewed yearly against Traditional Medicare rules by a utilization management committee (42 CFR 422.137).

Two protections that stop a denial from happening at all

Check these two before arguing the medicine.

An approval stands. If the plan approved something through prior authorization, a pre-service determination, or a concurrent decision during an inpatient or outpatient stay, it "may not deny coverage later on the basis of lack of medical necessity," and may reopen the approval only for good cause or on reliable evidence of fraud or similar fault (422.138(c)). Find the approval letter or the authorization number the doctor's office was given.

New enrollees get 90 days. If you joined the plan, or joined Medicare, in the middle of an active course of treatment, the plan must give you a transition period of at least 90 days in which it does not disrupt or require reauthorization of that treatment, even from an out-of-network provider (42 CFR 422.112(b)(8)). The same paragraph says an approved prior authorization for a course of treatment must stay valid "for as long as medically necessary to avoid disruptions in care."

Reconsideration: the one appeal you file yourself

The first appeal is called a reconsideration, and it goes to the plan.

Deadline. 65 calendar days from the date on the notice, as explained at the top (422.582(b); CMS's reconsideration page uses the same 65). Evidence that the letter reached you later lets you count from that date. If you miss the deadline, you can still file in writing with your reason, and the plan may extend the time for good cause (422.582(c)).

Who can file. You, your representative, or a physician who is treating you. A treating physician can request a standard pre-service reconsideration on your behalf without being appointed as your representative, but must give you notice that they are doing it (42 CFR 422.578).

How. A standard reconsideration request must be in writing unless the plan has a policy of accepting oral ones; your Evidence of Coverage says which. An expedited request can be oral or written (422.584(b)). The CMS notice asks for your name, address, member number, reasons for appealing, whether you want a standard or fast appeal and why, and any evidence.

Who decides. Someone who was not involved in the original denial. If the issue is medical necessity, the reconsideration must be made by a physician with expertise appropriate to the service (422.590(h)).

How fast.

The expedited rule works as it did at the first stage. A physician's request or support makes it mandatory; your own request leaves it to the plan (422.584(c)(2)).

If the plan reverses itself completely on a standard service request, it must authorize or provide the service within the same 30 days, counted from when it received your request (42 CFR 422.618(a)(1)).

If the plan says no again, you do not file the next step

This is where Medicare Advantage differs most from employer plans. When the plan upholds its denial, in whole or in part, it must send your case file with a written explanation to a CMS-contracted independent review entity within the same 30-day standard deadline (422.590(a)(2)), or within 24 hours of affirming an expedited denial (422.590(e)(5)). If the plan runs out the clock, that counts as an affirmation and the file goes anyway (422.590(d)). You do not fill out a form; once the deadline passes, call and ask for the date the file was forwarded.

The reviewer changed this year. According to CMS's Part C independent review entity page, C2C Innovative Solutions, Inc. is the Part C reviewer from 1 May 2026, while Maximus Federal Services continues processing reconsiderations it received through 30 April 2026, so for a while both issue decisions. CMS lists the reviewer's timeframes as 72 hours expedited, 30 calendar days for standard pre-service cases, and 7 calendar days for standard Part B drug cases.

You remain a party at this stage, and so does the plan (422.592(c)). The one situation where you file with the reviewer yourself is when the plan dismisses your reconsideration instead of deciding it, for example as late or filed by someone not allowed to file. Here the two sources do not match. The regulation says the written request is due "within 60 calendar days from the date of the MA organization's dismissal notice" (422.590(i)), with no five-day receipt presumption, while the CMS page says 65 calendar days and gives C2C's mailing address and fax number. Filing within 60 days of the date on the dismissal notice satisfies both.

If the reviewer reverses the plan on a service request, the plan must authorize the service within 72 hours of receiving the reversal, or provide it as quickly as your health requires and no later than 14 calendar days (422.618(b)(1)).

Past the independent reviewer

A further appeal goes to an Administrative Law Judge at the Office of Medicare Hearings and Appeals. The request is due within 60 calendar days of receiving the reviewer's decision, again presumed 5 days after its date (42 CFR 422.602), and the amount in controversy has to meet the annual threshold, which is $200 for requests filed in calendar year 2026 (90 FR 55869, CMS-4209-N). For a refused service, the projected value of the service counts toward that amount (422.600(c)). After the hearing come the Medicare Appeals Council and federal court, laid out in the five levels of a Medicare appeal.

Denials this process does not cover

A few decisions look like prior authorization denials but run on different rules.

• Prescription drugs under Part D are coverage determinations under 42 CFR Part 423, with their own timeframes. Part B drugs, the kind given in a doctor's office or infusion center, stay in the Part 422 process above. A CMS proposed rule of 14 April 2026, CMS-0062-P (91 FR 19890), would extend several prior authorization requirements to drugs; it is not final.
• The plan ending already-authorized coverage of an inpatient hospital stay, or of skilled nursing facility, home health agency, or comprehensive outpatient rehabilitation facility services, goes to a special expedited review by a Beneficiary and Family Centered Care Quality Improvement Organization, which bypasses the plan's reconsideration if you file on time (CMS, BFCC-QIO review). The termination notice gives the instructions.
• Dual-eligible integrated plans follow a combined Medicare-Medicaid process in 42 CFR 422.629 through 422.634, and the notice will carry Medicaid language, which can include a short window to keep services going during the appeal. If your card carries both programs, read it with how Medicaid fair hearings and continued benefits work.

What goes into the reconsideration

The plan's first decision rested on whatever the doctor's office sent. A new physician reads the file at reconsideration (422.590(h)), so what you add is the only thing that can differ. Match each piece to a sentence in the plan's stated reason.

1. The denial letter and the plan's stated reason, quoted exactly, with the date on the notice and the date you received it.
2. The coverage rule the plan applied. If the letter cites a policy, get it. If it cites nothing but "not medically necessary," say so and ask which Medicare coverage rule or published internal criterion the plan used.
3. A letter from the treating physician that answers the stated reason point by point: diagnosis, what has already been tried and for how long, why the requested item or level of care is needed now, and what happens if it is delayed. If the case is urgent, the letter should say that waiting could seriously jeopardize your health or ability to regain maximum function, which makes the expedited track mandatory.
4. Records the plan may not have had: therapy notes, imaging reports, specialist consults, a failed-treatment history. Label each with its date and source.
5. Any earlier approval or authorization number, if the plan approved something and is now refusing it (422.138(c)), and the date you enrolled, if the 90-day transition rule applies.
6. A request for your case file: the records and guidelines the plan used to decide.

Send it the way the letter specifies, keep copies, and write down the date the plan received it. That date starts the 30 days.

Where your plan's own approval numbers are posted

Under 42 CFR 422.122(c), every Medicare Advantage organization had to post on its website, by 31 March 2026, calendar year 2025 prior authorization data at the contract level: the items and services that require prior authorization, the percentages of standard and expedited requests approved and denied, the percentage approved after appeal, the percentage approved after an extension, and average and median decision times. The figures cover all items and services together, so they will not tell you how your procedure fares, but the "approved after appeal" number is your own plan's reversal rate rather than a national average.

Search the plan's website for "prior authorization metrics" or "prior authorization data." A large insurer may post many contracts; if you cannot tell which is yours, ask member services which contract your plan falls under. Then file before the reconsideration deadline, whatever the figure says.