If you're enrolled in a Medicare Advantage plan and your doctor recommends a treatment or prescription, it can be frustrating — and even alarming — to learn that your plan has denied it.
Unfortunately, this scenario is becoming more common. Medicare Advantage plans are increasingly using
prior authorization as a cost-control tool. While this process is designed to ensure care is medically necessary, it can also create delays, confusion, and unnecessary stress.
Here’s what you need to know — and what steps to take if your care is denied.
Why is prior authorization so common?
One of the trade-offs with Medicare Advantage plans is that, while they often have low or no monthly premiums and include extra benefits like dental, vision, and gym memberships, they also operate more like employer insurance — with provider networks and utilization management tools like prior authorization.
From 2019 through 2022,
prior authorization requests increased nearly 25% to 46 million annually. In 2022, insurers denied 3.4 million requests — about
7.4% of all submitted.
Worse yet, about
1 in 10 people who were denied care never filed an appeal, meaning they may have missed out on medically necessary services they were entitled to receive.
What to do if you're denied
If your Medicare Advantage plan denies your treatment or prescription,
don’t give up. There is a structured appeal process — and most denials that are appealed are eventually approved. Here's what to do:
1. Understand the denial
If your Medicare Advantage plan denies a medical service or prescription drug, they are required by law to provide you a written notice with a detailed and clear denial reason. If you do not receive a written denial notice, contact your insurer and ask for the
specific reason for the denial. This could be due to coding issues, incomplete information, or not meeting plan criteria.
2. Review your plan’s coverage rules
Familiarize yourself with what your plan is supposed to cover by reviewing your plan’s Evidence of Coverage or Member Handbook, which should be available on the plan’s website. They are also required to provide you a copy at the time of your enrollment and annually thereafter. Medicare Advantage plans cannot deny coverage for services covered under Original Medicare.
3. Work with your doctor
Ask your provider to help review the denial. They may be able to correct errors, supply additional documentation, or clarify the medical necessity.
How to file an appeal
If the issue can’t be resolved quickly, you’ll need to file a formal appeal. Your appeal should include:
- Your name, policy number, and the prior authorization number
- The date of the original request and the proposed service date
- The insurer’s reason for the denial and why you believe the request should be approved
- Supporting medical records or research studies
- Coverage guidelines from Medicare or your plan
- A signed letter from your doctor explaining the need for the service
If you feel that a delay in processing your appeal could seriously jeopardize your life or health or your ability to regain maximum function, you can request an
expedited appeal.
If the appeal is still denied
For medical services and drugs covered under Medicare Part B:
If your Medicare Advantage plan denies a medical service, in whole or in part, they will automatically forward it to an independent review entity (IRE) that will review and process the second-level appeal. You will receive a written decision from the IRE.
For prescription drugs covered under Part D:
A written second-level appeal must be submitted to the IRE by you, someone you appoint to represent you, or a physician, within 65 days of the written denial notice you received (unless you can show good cause for not meeting the 65-day timeframe).
If the IRE agrees with the plan’s denial of the service or prescription drug, there are additional levels of appeal. These are described in your Evidence of Coverage and/or Member Handbook.
