Special Situations

Medicare Advantage Plan Denied Your Claim

Name: Medicare Advantage Plan Denied Your Claim
Creator: Barley Billing Team
Published: 2026-03-26

Written by Barley Billing Team, Medicare Billing Experts | Last reviewed March 26, 2026

Does your notice say something like this?

"Your plan has denied coverage for this service"

"This service is not covered by your plan"

"The request does not meet the criteria for coverage"

"Your request for coverage has been denied"

If so, you're in the right place. Here's what it means and what to do.

What This Means

Your Medicare Advantage (MA) plan — the private insurance company that manages your Medicare benefits — has decided not to pay for a service, treatment, or item. This could be a denial of a prior authorization request (before you get the service) or a claim denial (after you already received the service).

Medicare Advantage plans are required to cover everything Original Medicare covers, but they may apply different rules about how and when services are approved.

Why This Happens

Prior authorization was required but not obtained. Many MA plans require pre-approval for certain services. If your provider didn’t get approval first, the plan may deny the claim.
The plan says the service isn’t medically necessary. Your plan reviewed the clinical information and decided the service didn’t meet its coverage criteria. This is the most common reason for MA denials.
The plan applied clinical criteria stricter than Original Medicare’s rules. A 2022 HHS Office of Inspector General report found that 13% of prior authorization denials involved services that would have been approved under Original Medicare.
You used an out-of-network provider. Most MA plans have provider networks. Services from out-of-network providers may not be covered, except in emergencies.
Missing or incomplete documentation. The plan may not have received enough medical records to support the request.

Should You Appeal?

Appeal outlook: Strong

Medicare Advantage denials have a very strong track record on appeal. According to KFF (2024), 80.7% of appealed MA denials were overturned at the first level. Yet only about 11.5% of denied requests are ever appealed, meaning many people accept denials they could have won.

The HHS Office of Inspector General found that 13% of MA prior authorization denials would have been covered under Original Medicare — meaning the plan’s own rules were too restrictive.

Individual results depend on your specific situation, but the data strongly favors appealing.

What To Do Next

Read your denial notice carefully. It must explain why your claim was denied and include instructions for how to appeal. Keep this notice — you’ll need it.
Note your deadline. You typically have 60 days from the date on the denial notice to file a first-level appeal (called a “reconsideration”). Don’t wait.
Call your doctor’s office. Ask them to provide a supporting statement or letter of medical necessity. Your appeal is stronger with your doctor’s backing.
File your appeal with your plan. Follow the instructions on your denial notice. For standard appeals, the plan must decide within 30 days. For expedited appeals (when delay could harm your health), the plan must decide within 72 hours.
If the plan upholds its denial, your case automatically goes to an Independent Review Entity (IRE) — an outside organization not connected to your plan. This is a key protection in the MA appeals process.
Get free help. Contact your State Health Insurance Assistance Program (SHIP) for free, unbiased counseling. You can also call 1-800-MEDICARE (1-800-633-4227).

Understanding the MA Appeal Levels

Level	Who Reviews	Timeline
Level 1: Reconsideration	Your MA plan	30 days (standard) or 72 hours (expedited)
Level 2: Independent Review	Independent Review Entity (IRE)	30 days (standard) or 72 hours (expedited)
Level 3: Hearing	Office of Medicare Hearings and Appeals	If amount meets threshold
Level 4: Review	Medicare Appeals Council	Additional review
Level 5: Court	Federal district court	If amount meets threshold

Sources

Want us to review your denial for free? Send us your notice and we'll tell you if it's worth appealing →

Appeal Deadlines — Check Your Notice for Exact Dates

Original Medicare

120 days from the date on your MSN

Medicare Advantage

At least 60 days (check your denial notice for exact deadline)

Not sure which you have? Check the top of your denial notice. If it names a private insurance company (like Humana, UnitedHealthcare, or Aetna), you have Medicare Advantage. If it says "Centers for Medicare & Medicaid Services," you have Original Medicare.

Frequently Asked Questions

What is the difference between Medicare Advantage and Original Medicare appeals?

With Original Medicare, your first appeal goes to a Medicare Administrative Contractor. With Medicare Advantage, your first appeal goes back to your plan for reconsideration. If the plan upholds its denial, an independent review organization automatically reviews it. The timelines are also different — MA plans must decide standard appeals within 30 days, while Original Medicare redeterminations take up to 60 days.

Can I switch to Original Medicare if my MA plan keeps denying claims?

You can switch during the Annual Enrollment Period (October 15 to December 7) or during the Medicare Advantage Open Enrollment Period (January 1 to March 31). Outside those windows, you generally cannot switch unless you qualify for a Special Enrollment Period.

Why do Medicare Advantage plans deny more claims than Original Medicare?

MA plans are private insurers that may apply their own clinical criteria, use prior authorization, and use automated review systems. A 2022 OIG report found that some MA plans applied coverage rules that were stricter than Original Medicare's requirements.

Should I ask for an expedited appeal?

If waiting for a standard decision could seriously harm your health or ability to function, you or your doctor can ask for an expedited (fast) appeal. The plan must decide within 72 hours. Your doctor's support strengthens this request.

Want Us to Check Your Denial?

Send us your denial notice and we'll review it for free. We'll tell you if it's worth appealing and exactly how to do it.

This information is for educational purposes only and is not legal or medical advice. Always verify with your doctor's office and insurance company.