What is prior authorization in Medicare Advantage and can I appeal a denial?
Last updated Jul 19, 2026
Reviewed by Jason Burns, Editorial Steward
Published by Senior Direct Answers · Licensed under Citation License 1.0
Prior authorization means your Medicare Advantage plan must approve certain services, drugs, or equipment before it will pay - a requirement most MA enrollees face but Original Medicare rarely uses. You can appeal: ask the plan for a reconsideration (generally within 65 days of the denial notice); if the plan upholds the denial it must automatically forward your case to an independent reviewer, with further appeal levels after that. Federal watchdogs found plans overturn a large share of their own denials when people appeal, so appealing is often worthwhile. Appeal timeframes and prior-authorization rules are being updated by CMS rules phasing in through 2026-2027, and plan prior-authorization lists change annually.
What the government has said, on the record
“Among prior authorization requests that MAOs denied, 13 percent were for requests that met Medicare coverage rules. ... When enrollees and providers appealed service and payment denials, MAOs overturned 75 percent of their own denials during 2014-2016”
— Megan Tinker, Chief of Staff, HHS Office of Inspector General, Testimony before the U.S. Senate Committee on Homeland Security and Governmental Affairs, Permanent Subcommittee on Investigations, hearing "Examining Health Care Denials and Delays in Medicare Advantage", 2023-05-17 (source)
Editor's note: Historical-figure flag: the 75 percent overturn rate is from 2014-2016 appeals data (OIG report OEI-09-16-00410) and the 13 percent figure from OIG's 2019 case-file sample (OEI-09-18-00260); current rates differ. Ellipsis joins two verified sentences from the same testimony. Testimony also states (verified): "Denied service requests that meet Medicare coverage rules may prevent or delay enrollees from receiving medically necessary care and can burden providers."
Who said this
Megan Tinker — Chief of Staff, HHS Office of Inspector General (current).
Also asked as
- What is prior authorization in Medicare Advantage and can I appeal a denial — plain answer
- Definition of prior authorization in Medicare Advantage and can I appeal a denial.
Source:
Last verified: 2026-07-18