Medicare Advantage said no. You may have appeal rights.
Medicare Advantage plans denied 4.1 million prior-auth requests in 2024. Medicare has defined appeal levels, deadlines, and documentation rules that are worth checking before you accept the first decision.
Upload your denial letter. Lysco drafts the appeal with Medicare citations, plan-specific policy references, and the deadline calendar. Your first review each month is free.
The numbers
53M
Prior-auth requests made to MA insurers in 2024
KFF, 2024
4.1M
Of those requests denied (7.7%)
KFF, 2024
+28%
More MA prior-auth denials in 2024 than in 2023 (4.1M vs 3.2M)
KFF, 2023 and 2024 data
5
Medicare appeal levels may be available
Medicare.gov
Aggregate data from published government and industry reports. Individual results vary by plan, provider, and circumstances.
What changed
What changed in 2026 for Medicare Advantage plans
The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) took effect January 1, 2026. Medicare Advantage plans already had to decide expedited requests within 72 hours and to explain a denial in the notice they send you. For non-drug prior-authorization requests, the rule added three things:
- A faster standard clock: standard (non-urgent) requests must be decided within 7 calendar days, down from 14. The 72-hour clock for expedited requests continues. These CMS-0057-F timeframes apply to Medicare Advantage (and Medicaid and CHIP) plans — not to prescription-drug prior authorization, marketplace plans or employer plans.
- A specific reason for the provider: when a request is denied, the plan must tell the provider who asked exactly why, however the decision is sent (portal, fax, email, mail or phone).
- Public numbers: plans must post their prior-auth metrics by March 31 each year, including how many requests were approved, denied, and approved after appeal.
A vague reason on an affected non-drug prior-authorization notice may support a procedural challenge or a request for a compliant explanation. It does not, by itself, establish coverage or predict that the decision will be reversed. Lysco can flag the notice issue and help you compare the stated reason with the plan and Medicare rules.
Denial playbook
Common reasons MA plans deny — and what works
Not medically necessary
MA plans must follow Medicare’s coverage rules (statute, regulations, NCDs, and LCDs). Where those rules are not fully established, a plan may apply its own internal criteria only if they are evidence-based and publicly posted (42 CFR 422.101(b)(6)). Lysco compares the criteria the denial cites with the applicable NCD or LCD, or with the plan’s published criteria.
Experimental or investigational
If Medicare itself covers the procedure, the MA plan must too. We cite the CMS manual sections that override the plan’s denial.
Out of network
Emergency care and post-stabilization are protected. We cite 42 CFR §422.113 and the continuity-of-care rules.
Missing documentation
KFF data shows many denials turn on administrative, coverage, or prior-authorization issues. We identify what’s missing and draft the appeal.
Helping a parent, spouse, or loved one?
If you are handling a Medicare Advantage denial for someone else, Lysco is built for that — you can upload a denial on behalf of someone else, and every appeal we draft uses the right language for a caregiver or authorized representative.
- No account juggling. One Lysco account can hold cases for multiple family members. Each case is kept separate and private.
- Representative-ready appeals. Every draft cites the correct CMS Appointment-of-Representative rules (CMS-1696) and, when needed, the plan’s authorized-representative process, to reduce the chance the plan rejects the appeal on a representation technicality.
- Post-acute and skilled-nursing denials. A 2023 lawsuit, Estate of Lokken v. UnitedHealth Group, alleges that an algorithm was used to deny post-acute care for seniors discharged from hospitals; those allegations have not been resolved. Whatever its outcome, post-acute denials deserve a close read — Lysco flags them specifically and cites Medicare’s own coverage standard alongside any plan criteria.
- Deadline tracking. Medicare Advantage appeal windows are short — a standard reconsideration request is due within 60 calendar days of receiving the denial, which CMS treats as 65 calendar days from the date on the notice (42 CFR 422.582(b)); expedited reviews run on a 72-hour decision clock. We calculate the deadline from the notice date and remind you before it closes.
The process
How Lysco prepares a Medicare Advantage appeal
Upload the denial letter
A picture, a PDF, or the letter text. Lysco identifies the stated reason and what needs checking.
Lysco identifies the real reason
We check the denial against Medicare coverage rules, your plan’s Evidence of Coverage, and the new 2026 transparency requirements.
We draft the appeal
With specific Medicare citations, plan policy references, and the right deadline. You review, edit, and send.
Escalation if needed
If your first appeal is denied, we guide you through the independent external review — binding on the plan.
Lysco is an informational tool — not a law firm, medical provider, or licensed patient advocate. Statistics cited are from published KFF analyses and CMS / Medicare.gov materials. Individual appeal outcomes vary by plan, denial reason, clinical evidence, and circumstances. This page is not legal or medical advice.