Medicare Advantage plans deny prior-authorization requests more often than people expect — and most denials are never appealed, even though a large share get overturned. Here's how the appeal works and the deadlines that matter.
Most prior-authorization denials come from Medicare Advantage plans requiring approval before a service, then saying it wasn't 'medically necessary' or wasn't documented. The key fact: denials are appealable, and a meaningful share are overturned on appeal — but only if you file. A written denial must include the reason and your appeal rights; read it for the specific reason, because that's what your appeal has to answer.
Medicare has a five-level appeals process: (1) redetermination/reconsideration by the plan; (2) review by an Independent Review Entity; (3) a hearing with an Administrative Law Judge; (4) the Medicare Appeals Council; (5) federal court. Most cases are resolved at the first two levels. Each level has its own deadline and its own form — don't skip a level.
For a Medicare Advantage service denial you generally have 60 days from the denial notice to file the first-level appeal. If waiting could seriously harm your health, you (or your doctor) can request an expedited (fast) appeal, which the plan must decide much faster — typically within 72 hours. Mark the 60-day clock the day the denial arrives; missing it usually means starting over with a 'good cause' request.
Gather the denial letter, your doctor's supporting statement (why the service is medically necessary), and any records that back it up; follow the appeal instructions on the denial notice; and keep copies of everything you send with dates. A letter from the prescribing doctor is the single most useful piece — it directly answers the 'not medically necessary' reason most denials cite.
If you're the agent helping clients through denials, our Medicare Appeals & Prior-Auth Toolkit auto-calculates the 60-day file-by deadline, logs every prior-auth and appeal across the 5 levels, and includes redetermination, expedited, and good-cause letter templates — Excel + Google Sheets, $24.
These free tools handle one client at a time. Our Excel + Google Sheets toolkits run your whole book — client CRM, 60-day renewal radar, IRMAA appeals, commission & chargeback tracking, and compliance logs. Built for agents, instant download, no monthly fee.
New here? Start for $7.49 →Don't buy the whole system on faith. Grab the Medicare AEP Tracker — your daily command center for enrollment season — for $7.49, instant download. See exactly how our Excel + Google Sheets tools work, then scale up to the full agent CRM when you're ready.
Get the $7.49 AEP Tracker →The dates, penalties, IRMAA brackets, and compliance rules agents reference all season — one page, 2026-current. Get it free, plus occasional tools that save you time.
For a Medicare Advantage service denial you generally have 60 days from the date of the denial notice to file the first-level appeal. If you miss it, you can ask for more time with a 'good cause' explanation, but it's far easier to file within the 60 days.
A fast-tracked appeal you can request when waiting for a standard decision could seriously harm your health. You or your doctor can ask for it, and the plan must decide much faster than a standard appeal — typically within 72 hours.
Five: redetermination/reconsideration by the plan, review by an Independent Review Entity, an Administrative Law Judge hearing, the Medicare Appeals Council, and finally federal court. Most appeals are resolved in the first two levels.
Often, yes. A meaningful share of prior-authorization denials are overturned on appeal, but most are never challenged. A supporting letter from your doctor explaining medical necessity is the most effective piece of an appeal.
Figures on this page are verified against U.S. government primary sources: