Insurance denials
Medicare Advantage denied a service Original Medicare would cover
Medicare Advantage plans contract with CMS to cover at least everything Original Medicare covers. The HHS Office of Inspector General has issued repeated audit reports finding that some MA plans deny services Original Medicare would have approved. Beneficiaries have a federally-mandated appeal process designed for this.
Federal basis
Medicare Advantage Coverage Standards + Appeals
42 CFR §422.566 / OIG MA Audit Reports
Read the source →What this looks like in practice
Medicare Advantage (Part C) plans are private insurance products that take CMS-paid premiums in exchange for providing Medicare benefits. Federal rules require they cover all services Original Medicare covers; the plan's network rules and prior-auth process can shape HOW services are accessed but can't restrict WHAT is covered relative to Original Medicare.
The OIG's 2022 report on MA denials (OEI-09-18-00260) found that 13% of denied prior-authorization requests would have been covered by Original Medicare — meaning MA plans were systematically inappropriately denying services. Reasons included documentation requirements stricter than CMS uses and clinical criteria narrower than Medicare's.
The MA appeal process is multi-stage: reconsideration by the plan, then independent review (Maximus is the typical contractor), then ALJ hearing, Medicare Appeals Council, and federal court. The first two stages reverse a meaningful share of denials.
How to spot it on a bill
- 01.You're enrolled in a Medicare Advantage plan (Part C).
- 02.A service was denied by the MA plan.
- 03.Original Medicare (Part A and B) would have covered it — Medicare.gov's coverage tool can confirm.
What to write — ready-to-paste language
Replace the bracketed fields with your specific details. Send by certified mail with return receipt, or via the hospital’s patient portal if it offers documented messaging. Keep a copy.
I am appealing the Medicare Advantage plan denial of [service] on [date]. Per 42 CFR §422.101(b), Medicare Advantage plans must provide coverage equal to Original Medicare. The OIG has documented (OEI-09-18-00260) that MA plans regularly deny services Original Medicare would cover. Please review whether Original Medicare would have approved this service under the standard CMS coverage criteria. I am requesting (1) plan reconsideration, and (2) automatic forwarding to the Independent Review Entity (currently Maximus) if reconsideration upholds the denial.
This is a starting point, not legal advice. Your specific situation may warrant additional details. Our scan tool drafts this letter automatically with your bill’s specifics filled in.
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Related scenarios
Insurance denied for 'not medically necessary' — your appeal rights
ERISA and ACA give every insured patient the right to appeal denied claims. Internal and external review processes are mandatory; insurers must follow specific timelines.
Service denied because prior authorization wasn't obtained
When the doctor's office didn't get prior auth and your insurance denies the claim, the hospital often bills the patient. Federal rules and many state laws push that liability back to the provider.
Step therapy denied — must try cheaper drug first
'Step therapy' or 'fail first' rules require trying a lower-cost drug before insurance covers a more expensive one. Federal and most state laws give patients a way to bypass when medically necessary.
Common questions
How do I know if Original Medicare would have covered the service?
How long does the MA appeal take?
P.S. The dispute language above is a starting point. Bills with this pattern often have additional issues alongside it — coding errors stacked with markup, surprise bills stacked with charity- care eligibility. The scan finds all of them in one pass. Start the audit →
P.P.S.Federal law gives you these rights regardless of how the bill arrived. Insured, uninsured, in-network, out-of-network — the underlying patient-protection statutes apply.
P.P.P.S. Bills are time-sensitive. Most insurance appeals must be filed within 180 days. Charity-care discounts at non-profit hospitals are most easily applied within 240 days of the original bill. Acting earlier costs less.