Medicare Advantage: your appeal rights
Medicare Advantage has the strongest appeal machinery in American health insurance — five levels, automatic escalation, and an 80% overturn rate for those who use it.
Is this you? You have a Medicare plan run by a private insurer (an “MA” or “Part C” plan) — the card says Medicare Advantage, and the insurer is a company like UnitedHealthcare, Humana, or Aetna.
The escalation ladder
Your specific rights
Your Medicare Advantage plan must give you a written decision when it denies a service or payment. Standard requests must be decided within 72 hours for services (14 days for payment). If the plan misses its deadline, the request is treated as approved under the 2026 deemed-approval rule.
You have 65 days from the date on your denial notice to ask the plan to reconsider. A different reviewer than the one who denied you must decide. If the denial was for medical reasons, a doctor with relevant expertise must review it.
If your plan upholds its denial, it must automatically forward your case to an Independent Review Entity — you don't have to ask. The IRE is not part of your insurance company. This automatic escalation is unique to Medicare Advantage and is one reason appealed MA denials get overturned so often.
If waiting the standard timeline could seriously harm your health or your ability to function, you can demand an expedited appeal decided within 72 hours. If any doctor supports the fast track — including the one asking for the service — the plan must grant it.
If the IRE also says no and the amount in dispute meets the yearly threshold, you can request a hearing before an Administrative Law Judge within 60 days. Levels 4 and 5 (Medicare Appeals Council, federal court) exist beyond that.
Under the 2026 prior-authorization rules, impacted payers must give a specific reason for a prior-auth denial — not boilerplate. Ask for the exact criteria used, the guideline relied on, and the credentials of the reviewer. Vague denials are appealable on process alone.
Insurers must cover emergency care based on your symptoms at the time — not the final diagnosis. If a reasonable person would have thought it was an emergency, it must be covered as one, in or out of network, with no prior authorization required.
For emergency care and for out-of-network providers working at in-network facilities, you can only be billed your in-network cost sharing. Balance bills in those situations are illegal — dispute them rather than paying.
What to include in your appeal
- The denial notice (Notice of Denial of Medical Coverage)
- A letter of support from the treating physician
- Medical records relevant to the denied service
- The plan's own criteria, with a point-by-point response
- Expedited-review request if delay risks your health