How to appeal a Medicare Advantage denial
The short answer
You have 65 days from the date on the Medicare Advantage plan’s denial notice to ask it to reconsider. If the plan keeps any part of its denial, it must send your case to an independent reviewer on its own; you do not have to file a second request.
Deadlines, decision times and your rights
These are the limits in the federal rules. Your plan can give you more time but not less. If your denial letter prints an earlier date, go by the earlier one.
Deadline to appeal
60 days from when you receive the denial (counted as 65 days from the notice date)
Rule: 42 CFR 422.582(b)
What the rule says
Except as provided in paragraph (c) of this section, a request for reconsideration must be filed within 60 calendar days after receipt of the written organization determination notice.
60 days from when you receive the denial (counted as 65 days from the notice date)
Rule: 42 CFR 422.584(b)
What the rule says
A request for reconsideration must be filed within 60 calendar days after receipt of the written organization determination notice.
Call the Quality Improvement Organization no later than the day you are discharged
Rule: 42 CFR 422.622(b)(1)
What the rule says
The request must be made no later than the day of discharge and may be in writing or by telephone.
By NOON of the day after you receive the termination notice
Rule: 42 CFR 422.626(a)(1)
What the rule says
An enrollee who desires a fast-track appeal must submit a request for an appeal to an IRE under contract with CMS, in writing or by telephone, by noon of the first day after the day of delivery of the termination notice. If, due to an emergency, the IRE is closed and unable to accept the enrollee's request for a fast-track appeal, the enrollee must file a request by noon of the next day that the IRE is open for business.
How long they have to decide
30 days after the plan receives your request
Rule: 42 CFR 422.590(a)(1)
What the rule says
Except as provided in paragraph (f) of this section, if the MA organization makes a reconsidered determination that is completely favorable to the enrollee, the MA organization must issue the determination (and effectuate it in accordance with § 422.618(a)) as expeditiously as the enrollee's health condition requires, but no later than 30 calendar days from the date it receives the request for a standard reconsideration.
60 days after the plan receives your request
Rule: 42 CFR 422.590(b)(1)
What the rule says
If the MA organization makes a reconsidered determination that is completely favorable to the enrollee, the MA organization must issue its reconsidered determination to the enrollee (and effectuate it in accordance with § 422.618(a)(2)) no later than 60 calendar days from the date it receives the request for a standard reconsideration.
7 days after the plan receives your request
Rule: 42 CFR 422.590(c)(1)
What the rule says
If the MA organization makes a reconsidered determination that is completely favorable to the enrollee, the MA organization must issue the determination (and effectuate it in accordance with § 422.618(a)(3)) as expeditiously as the enrollee's health condition requires, but no later than 7 calendar days from the date it receives the request for a standard reconsideration. This 7 calendar-day period may not be extended under the provisions in paragraph (f) of this section.
72 hours after the plan receives your fast request
Rule: 42 CFR 422.590(e)(1)
What the rule says
Except as provided in paragraph (f) of this section, an MA organization that approves a request for expedited reconsideration must complete its reconsideration and give the enrollee (and the physician involved, as appropriate) notice of its decision as expeditiously as the enrollee's health condition requires but no later than 72 hours after receiving the request.
The next level
60 days from when you receive the independent reviewer's decision (counted as 65 days from its date)
Rule: 42 CFR 422.602(b)(1)
What the rule says
Except when an ALJ or attorney adjudicator extends the time frame as provided in part 405 of this chapter, a party must file a request for a hearing within 60 calendar days of receipt of the notice of a reconsidered determination.
Your rights along the way
- Missed the deadline? Ask for more time for good cause. The plan may accept a late reconsideration request if you show good cause. 42 CFR 422.582(c)(1)
- If the plan upholds the denial, it goes to an independent reviewer automatically. You do not have to file again: an upheld denial is sent to the Independent Review Entity for you. 42 CFR 422.592(a)
- If the plan misses its deadline, the case goes to the independent reviewer. A late plan decision counts as a denial and must be sent to the Independent Review Entity. 42 CFR 422.590(d)
- The denial notice must give specific reasons. A Medicare Advantage denial must state the specific reasons and explain your appeal rights. 42 CFR 422.568(e)
- Present evidence in person or in writing. The plan must give you a reasonable chance to present evidence and arguments, in person and in writing. 42 CFR 422.586
- A doctor with the right expertise must review medical-necessity denials. Medical-necessity reconsiderations must be decided by a physician with expertise appropriate to the services at issue. 42 CFR 422.590(h)(2)
Each rule links to its text in the Electronic Code of Federal Regulations. Checked against the regulation text on November 10, 2026. The Lamdis app works out your dates from these same rules.
Where the 65 days come from
The rule says you must file within 60 calendar days after you receive the notice, and Medicare presumes you received it 5 days after the date printed on it (42 CFR 422.582(b)). Medicare.gov puts it simply: 65 days from the date on the initial denial notice. If you miss it, you can still file and explain why you were late.
The five levels
- Reconsideration by your plan. 30 days for care you haven’t had, 60 days for a bill, 7 days for a Part B drug, 72 hours if expedited (42 CFR 422.590).
- Independent Review Entity. Automatic if the plan keeps any part of its denial (42 CFR 422.592(a)).
- Hearing with an administrative law judge, requested within 60 days, if the amount at stake is high enough (42 CFR 422.602(b)(1)).
- Medicare Appeals Council.
- Federal district court.
Medicare.gov describes each level, and every decision letter tells you how to move to the next one.
Ask for a fast appeal when it matters
If waiting 30 days could seriously harm your life, health or ability to regain function, ask for an expedited appeal. The plan must decide within 72 hours if it agrees, or if your doctor tells the plan, that waiting could do that harm (Medicare.gov).
If a hospital, skilled nursing facility, home health agency or hospice is ending your covered care, there is a separate fast appeal to an independent reviewer called a BFCC-QIO. The notice you get explains how (Medicare.gov).
The plan has to follow Medicare’s coverage rules
A Medicare Advantage plan must cover the services Original Medicare covers (42 CFR 422.101(a)). It can use its own coverage criteria only when Medicare’s rules don’t fully spell them out, and those criteria must rest on current evidence and be publicly accessible (42 CFR 422.101(b)(6)). If your denial cites a plan guideline, ask for it and compare it with Medicare’s own rule for that service.
Free help
Your State Health Insurance Assistance Program (SHIP) gives free, one-on-one counseling to people with Medicare (Medicare.gov). Find your local SHIP.
Questions people ask
How long do I have to appeal a Medicare Advantage denial?
65 days from the date on the plan’s denial notice (Medicare.gov).
Do I need to ask for the independent review myself?
No. If the plan upholds its denial in whole or in part, it must forward your case to the Independent Review Entity (42 CFR 422.592(a)).
Can my doctor appeal for me?
For care you haven’t had yet, your doctor can ask for a reconsideration on your behalf (Medicare.gov).
Are Medicare Advantage appeals worth it?
In 2024, Medicare Advantage insurers fully or partly overturned 80.7% of the prior-authorization denials that were appealed, but only 11.5% of denials were appealed (KFF).
Sources
- Medicare.gov: Appeals in Medicare health plans
must file an appeal within 65 days from the date on the initial denial notice sent by your plan
- eCFR: 42 CFR 422.582, Request for a standard reconsideration
The date of receipt of the organization determination is presumed to be 5 calendar days after the date of the written organization determination, unless there is evidence to the contrary.
- eCFR: 42 CFR 422.590, Timeframes and responsibility for reconsiderations
no later than 72 hours after receiving the request
- eCFR: 42 CFR 422.592, Reconsideration by an independent entity
the issues that remain in dispute must be reviewed and resolved by an independent, outside entity that contracts with CMS
- eCFR: 42 CFR 422.101, Requirements relating to basic benefits
MA organizations may create publicly accessible internal coverage criteria that are based on current evidence in widely used treatment guidelines or clinical literature when coverage criteria are not fully established in applicable Medicare statutes, regulations, NCDs or LCDs.
- Medicare.gov: Fast appeals
With a fast appeal, an independent reviewer, called a Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO), will decide if your covered services should continue.
- Medicare.gov: Filing an appeal
SHIPs are state programs that get money from the federal government to give free local health insurance counseling to people with Medicare.
- SHIP Technical Assistance Center: Get Medicare Help from Your Local SHIP Program
Get one-on-one counseling from a trusted, unbiased source.
- KFF: Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024
most appeals (80.7%) were partially or fully overturned in 2024
This page is general information about appeal rules in the United States. It is not legal or medical advice. Rules can change, and your plan’s documents and your denial letter control the dates that apply to you.