Medicare Advantage: your appeal rights

Your Medicare Advantage plan must give you a written decision when it denies a service or payment. A standard service decision is due within 14 calendar days (7 calendar days for items subject to prior authorization, beginning January 1, 2026); an expedited decision within 72 hours (24 hours for a Part B drug); a payment decision within 60 calendar days. If the plan misses its deadline, that failure itself counts as a denial you can appeal — it is not an automatic approval.

You have 65 calendar 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.

If your Medicare drug plan (including MA-PD plans) says a drug isn't on the formulary, wants you to try another drug first, limits the dose, or puts it on an expensive tier, you can demand an exception. Your prescriber submits a supporting statement — that the formulary alternatives would not be as effective for you, would cause adverse effects, or both — and the plan must decide within 72 hours (24 hours expedited) of receiving that statement. An exception request IS a coverage determination; if the plan misses its deadline, your case must be automatically forwarded to the independent review entity within 24 hours.

An MA plan may apply step therapy to physician-administered (Part B) drugs only for NEW starts — if you've received the drug within the past 365 days, step therapy can't be applied to you. Step-therapy programs must be approved by the plan's pharmacy and therapeutics committee. Relief runs through the normal organization-determination track, where a decision on a Part B drug is due in 24 hours when expedited.

Under the 2026 CMS prior-authorization rule (CMS-0057-F), impacted payers — Medicare Advantage plans, Medicaid and CHIP (fee-for-service and managed care), and Qualified Health Plans on the federal Marketplace — must give a specific reason for a prior-authorization denial, not boilerplate. Ask for the exact criteria used, the guideline relied on, and the reviewer's credentials. A vague, non-specific denial gives you strong grounds to challenge the decision. (This rule does not reach most commercial or self-funded employer/ERISA plans.)

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. (Ground ambulance bills are not covered by these protections.)