My Medicare Advantage plan denied a service. How does the appeal work?

Health insuranceAppealChecked Nov 5, 2026

From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-05 · Source: Medicare.gov · Appeals in Medicare health plans · Level 1 (row ma-l1-file-mgov) View original ↗

In short

First ask your plan to look again.
File within 65 days from the date on the denial.
If the plan still says no, it sends your case to an outside reviewer.

What this means

• Level 1 — reconsideration by your plan. Medicare.gov says you, your representative or your doctor must file within 65 days from the date on the plan's initial denial notice, and give a reason if you file late [1]. The regulation states the same deadline as 60 calendar days after receipt, with receipt presumed 5 calendar days after the notice date [2]. For a standard reconsideration the plan decides within 30 calendar days for a service or item, 60 calendar days for a payment request, and 7 calendar days for a Part B drug [3]. • Level 2 — Independent Review Entity. If the plan keeps its denial in whole or in part, it must send the case file to the independent entity contracted by CMS. You do not file this step yourself [4]. • Level 3 — OMHA: 60 days from the date of the IRE's decision; for 2026 the minimum amount is $200 [5]. • Levels 4 and 5 — Medicare Appeals Council, then federal district court: 60 days at each step; for 2026 the court minimum is $1,960 [6].

Your next step

+ deadline: file Level 1 within 65 days from the date on the denial notice [1].

Where this comes from (6)

[1] Medicare.gov · Appeals in Medicare health plans · Level 1 (row ma-l1-file-mgov) · checked 2026-11-05
You, your representative, or your doctor or healthcare provider must file an appeal within 65 days from the date on the initial denial notice sent by your plan . If you miss the deadline, you must give a reason for filing late.
[2] eCFR · 42 CFR 422.582(a)-(b) (row ma-l1-file) · checked 2026-11-05
a request for reconsideration must be filed within 60 calendar days after receipt of the written organization determination notice. (1) The date of receipt of the organization determination is presumed to be 5 calendar days after the date of the written organization determination
[3] eCFR · 42 CFR 422.590(a)-(c) (row ma-l1-decide) · checked 2026-11-05
no later than 30 calendar days from the date it receives the request for a standard reconsideration. … Requests for payment. … no later than 60 calendar days … Requests for a Part B drug. … no later than 7 calendar days
[4] eCFR · 42 CFR 422.590(a)(2) (row ma-l2-auto) · checked 2026-11-05
If the MA organization makes a reconsidered determination that affirms, in whole or in part, its adverse organization determination, it must prepare a written explanation and send the case file to the independent entity contracted by CMS
[5] Medicare.gov · Level 3 (row ma-l3) · checked 2026-11-05
You have 60 days from the date of the IRE's decision to ask for a level 3 appeal … For 2026, the minimum dollar amount is $200.
[6] Medicare.gov · Level 4 · Level 5 (row ma-l4l5) · checked 2026-11-05
You have 60 days after you get the decision to move to appeals level 4 … For 2026, the minimum dollar amount is $1,960. … You have 60 days after you get the Appeals Council's decision to ask for judicial review by a federal district court.

How we found this

We matched your question to 6 official sources, quoted the exact lines, and re-checked each quote against its source on 2026-11-05.

What we don’t know yet

Your own plan or notice may say something different. If your letter cites another rule, send it and we will look again.

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Information only — not legal advice. Your plan, insurer or agency decides.

This answer quotes the official sources listed above, with the date we checked them. Your own policy, notice and state rules control. We are not your lawyer or your insurer. We don’t file, argue or negotiate claims for you — you send any letter or form yourself.

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