Medicare Advantage Denials: How To Appeal and Win

Healthcare costs make up a large portion of older adults’ budgets. Even with Medicare Advantage and drug plans, medical care burns through their savings. Before getting treatment with your Medicare Advantage plan, you may need prior authorization.

When your insurance company denies a Medicare-covered service request, you will have to pay out of pocket for your care. Many patients avoid seeking the sought treatment because they can’t afford it. This can result in serious medical issues for patients needing care.

You can file a Medicare Advantage appeal to challenge the coverage denial. However, you must follow the appeals process and provide supporting documentation to show why they made an error. Contact an elder law attorney for legal advice about making a successful appeal.

Understanding Medicare Advantage

When older people first qualify for Medicare at age 65, they can quickly get lost in the alphabet soup of Medicare planning. Medicare Part A covers hospital care. Part B is for medical insurance. The Centers for Medicare & Medicaid Services (CMS) administers the original Medicare program and benefits.

Medicare Advantage Plans (Medicare Part C) combine Parts A and B to fill some care gaps that traditional Medicare does not cover. About half of Medicare recipients enroll in Medicare Advantage plans offered by private companies that contract with the government. Many of these private insurance plans also include Part D for prescription drug coverage.

Like other private healthcare insurance, Medicare health plans vary in the types of health services covered, deductibles, premiums, and out-of-pocket spending limits. These include PPO or HMO managed care plans. Most enrollees also need prior authorization for some care services, including hospital stays and skilled nursing facility care.

In 2024, Medicare Advantage providers made rulings on more than 50 million prior authorization requests. Of those, insurance providers denied 7.7 percent of all prior authorization requests. However, most enrollees never appeal those denied requests. When enrollees did file appeals, the decisions were partially or fully overturned more than 80% of the time.

Why Are Medicare Advantage Claims Denied?

Medicare Advantage providers can deny prior authorization requests for many reasons. Some of the most common reasons why insurance providers deny authorization requests include:

• No medical necessity
• Out-of-network provider
• Lack of supporting documentation
• Service is not covered by the insurance plan
• Treatment before getting prior authorization

The insurance company may also deny your claim based on administrative or clerical errors. For example, the doctor or insurance company may make an error in insurance coding that shows your treatment as not medically necessary or as an uncovered service.

When your Medicare Advantage provider sends you a service denial letter, the letter should indicate the specific reasons why they denied your prior authorization. The notification should also provide information on the Medicare appeals process.

The Medicare Advantage Appeals Process

You can file an appeal if your Medicare Advantage provider denied a prior authorization request, denied a claim, or stopped covering a necessary drug or treatment.

There are multiple levels of appeal, ranging from your Medicare Advantage provider to claims in federal court.

Level 1 Appeals

Level 1 appeals start with a Health Plan Reconsideration. You can ask for a reconsideration of the provider’s decision, with supplemental documentation, additional information from your doctor, and other evidence to support your appeal.

When filing your appeal, make sure to include the following information:

• Name, address, and Medicare number
• Service or request you are appealing, including the dates
• Reason for the appeal
• Name of your representative (if appointed)
• Additional information to support your appeal

You can also request an expedited appeal if necessary. The standard timeline for a pre-service prior authorization request denial is 30 days. The timeframe for other types of appeals may vary.

Level 2 Appeals

If your Medicare Advantage provider denies your reconsideration request, you can elevate the appeal to the next level.

Your provider should forward their decision to an Independent Review Entity (IRE). The IRE will generally respond to the provider’s decision within 30 days for a pre-service denial.

Level 3 Appeals

If the IRE denies your claim, you can appeal your case to the Office of Medicare Hearings and Appeals (OMHA).

You can request a hearing or have the OMHA make the decision without a hearing. You can request a hearing with an Administrative Law Judge (ALJ). The ALJ will independently review your appeal and give you a chance to offer testimony.

Level 4 Appeals

The next level of appeal is before the Medicare Appeals Council. You can request a review of the ALJ’s decision, including why you disagree with the judge’s decision.

Level 5 Appeals

The final level of appeal is in the federal district court. To qualify, your claim must involve a minimum dollar amount. At this stage, you have exhausted all other remedies for appeal. The federal judge will review the case and issue a determination.

For questions about this level of Medicare appeals, talk to an experienced Medicare appeals attorney.

What Is the Deadline To File a Medicare Advantage Appeal?

• Level 1 Appeals: For most Medicare Advantage appeals, you have to make a request for reconsideration within 65 days from the date of the denial notice. However, you may be able to appeal after 65 days if you provide a reason for late filing.
• Level 2 Appeals: Automatic
• Level 3 Appeals: You have 60 days from the date of the IRE’s decision to request an appeal by the Office of Medicare Hearings and Appeals.
• Level 4 Appeals: You have 60 days after getting a decision by the OMHA or ALJ to request a Medicare Appeals Council review.
• Level 5 Appeals: You have 60 days after getting a decision by the Medicare Appeals Council to ask for a review by a federal district court.

Can Someone File an Appeal On My Behalf?

Contact your State Health Insurance Assistance Program (SHIP) for information about navigating Medicare and where to find information about filing an appeal. These resources can help you get started with the appeals process. However, if your case goes to court, they do not provide legal representation.

You can also appoint a family member or loved one as a representative to file an appeal on your behalf. You can file an Appointment of Representative form with CMS and include the form with your appeal to the contractor listed on your Medicare Summary Notice or Medicare Advantage plan.

You can also contact an attorney to represent you in your Medicare Advantage appeal. Elder law attorneys understand the appeals process and your legal rights to get covered care. If your appeal escalates to judicial review in court, an attorney can also represent you before the Administrative Law Judge (ALJ).

How Can an Attorney Help With Medicare Advantage Appeals?

Medicare is tough to navigate for many people. When Medicare Advantage providers deny a prior authorization request, most people give up. However, if you appeal the initial decision, you have a good chance of having the request overturned. It is a hassle to go through the appeals process. However, it could be necessary for your health and well-being.

For more information about appealing a Medicare Advantage denial, talk to a local elder law attorney.