How to Appeal a Medicare Advantage Denial — and Why Most Appeals Win

Medicare Advantage plans deny millions of prior authorization requests every year. Here is the statistic every practice should have taped to the billing office wall: when those denials are appealed, over 80% are overturned — yet fewer than one in five denials is ever appealed at all. The gap between those two numbers is money your practice earned and care your patients were prescribed, surrendered without a fight.

Why MA appeals win so often

Three structural reasons:

• Initial denials are often automated or cursory. The first review may never have meaningfully engaged with the chart. An appeal forces human clinical review.
• Plans are bound by Medicare's coverage rules. Under CMS regulations, MA plans must cover what traditional Medicare covers and must follow Medicare's coverage criteria (NCDs and LCDs) where they exist. Plans cannot lawfully apply internal criteria more restrictive than Medicare's own. Many denials do exactly that — and citing the rule reverses them.
• Upheld denials get automatic outside review. Unique to Medicare Advantage: if the plan upholds its own pre-service denial, it must automatically forward the case to an Independent Review Entity (IRE) — an outside reviewer the plan doesn't control, at no cost to you.

The appeal process, step by step

1. File the plan reconsideration within 60 days

The standard window to request reconsideration is 60 days from the denial notice. For pre-service requests the plan must decide within set timeframes — and if waiting could jeopardize the patient's health, request an expedited appeal, which the plan must decide within 72 hours. A physician's statement that the standard timeline endangers the patient generally compels the expedited track.

2. Build the appeal on Medicare's criteria, not the plan's

Identify the applicable coverage rule — the NCD or LCD for the service. Then map the chart against it, criterion by criterion, with a date-stamped citation for each. If the plan's denial letter cited internal guidelines stricter than the LCD, say so explicitly: "The plan's criteria may not be more restrictive than Medicare's applicable coverage criteria; the attached chart satisfies the LCD in effect on the date of service."

3. Include a focused physician statement

One page from the treating physician stating the diagnosis, the failed alternatives with dates, and why the denied service is medically necessary for this patient. Signed and dated. This carries disproportionate weight at both the plan and IRE levels.

4. If upheld, let the automatic IRE review work

You don't file anything new — the plan must forward the case. But the record it forwards is the record you built. This is why the reconsideration packet should be complete: it's also your IRE packet.

5. Beyond the IRE

For qualifying amounts, further levels exist — Administrative Law Judge hearing, Medicare Appeals Council, and federal court. Few cases need to go that far; most winnable appeals win at reconsideration or the IRE.

What to include in every MA appeal packet

• The denial letter and the plan's stated rationale
• The applicable NCD/LCD criteria, quoted
• A criteria-by-criteria evidence map with dated chart citations
• The physician's medical-necessity statement
• Relevant records: imaging reports, conservative-therapy documentation, prior treatment outcomes