Medicare Prior Authorization and Appeals: What to Do When Care Is Delayed or Denied

These terms are often used together, but they do different jobs. A Medicare Advantage or Part D plan can require prior authorization for certain covered services or drugs. That is a request for the plan to approve coverage before you receive the item, service, or medication. Some plans also use other coverage rules, such as step therapy, quantity limits, referrals, or in-network requirements.

A coverage determination is the plan's decision about whether it will provide or pay for the benefit. In Medicare Advantage, you may see the term organization determination. In Part D, a coverage determination can include a request for a drug the plan does not list, a lower cost-sharing tier, or a waiver of a utilization-management rule. A grievance is different. It is generally for dissatisfaction with a plan's service, communication, or quality of care rather than a request to reverse a coverage decision.

If the decision is unfavorable, an appeal asks Medicare or the plan to reconsider it. Medicare.gov explains that the appeal process varies by coverage type and generally has five levels. Use the instructions in the written decision for your specific coverage instead of relying on a general timeline.

Start by asking the plan for the exact reason. Find out whether the issue is medical-necessity documentation, a prior authorization requirement, an out-of-network provider or supplier, a formulary rule, a missing referral, a coding issue, or a coverage exclusion. Ask for the decision in writing if you do not already have it.

Then contact the clinician, prescriber, provider, or supplier involved. Ask what documentation was submitted and whether additional records, an order, a supporting statement, or a different covered option may be appropriate. Your clinician is the right person to advise you about treatment. A licensed Medicare specialist can help you understand plan choices and enrollment rules, but cannot replace a clinician's medical judgment.

Before paying a bill or changing coverage, gather your Medicare Summary Notice or plan Explanation of Benefits, the prior authorization or denial notice, the name of the plan representative, and the date of every call. If the issue involves durable medical equipment, review our Medicare mobility-scooter coverage guide for examples of why documentation and supplier rules matter. If it involves a plan changing a doctor or medication, use our dropped doctor or drug FAQ and its printable action checklist.

A Part D plan's drug list is called a formulary. When the issue involves a drug that is not on the formulary, a higher cost-sharing tier, step therapy, prior authorization, or a quantity limit, you may be able to request an exception. CMS states that a formulary exception or tiering exception is a type of coverage determination.

For a formulary exception, the prescriber must support why the requested drug is medically necessary because covered alternatives would not be as effective or would have adverse effects. For a tiering exception, the supporting statement addresses why lower-tier preferred drugs would not be as effective or would cause adverse effects. CMS says that after the plan has the supporting statement, it must give a written decision on a benefit request within 24 hours for an expedited request or 72 hours for a standard request.

If the plan denies the request, the decision includes information for requesting a redetermination. Review our Medicare Part D guide and Zepbound coverage guide for related drug-coverage questions, but use your own plan documents and prescriber's advice for the medication at issue. For official rules, see the CMS Part D exceptions guidance.

The appeal route depends on whether you have Original Medicare, a Medicare Advantage plan, or a Medicare drug plan. Medicare.gov describes five general appeal levels, but the initial request, review organization, and timing differ by coverage type. That is why the written decision letter is the most important starting document.

For Medicare Advantage and Part D decisions, the plan must tell you in writing how to appeal. Read the notice carefully, including where to send the request, what documents to include, and whether a fast review can be requested. For Original Medicare, the Medicare Summary Notice explains how to begin. When you need help understanding an appeal, Medicare.gov also identifies the State Health Insurance Assistance Program, or SHIP, as a free source of personalized local counseling.

A favorable appeal can change the coverage or payment decision. An appeal does not replace an enrollment decision, and it does not automatically mean that a person can change plans. If your coverage problem is tied to a move, plan termination, non-renewal, or another qualifying event, see our Special Enrollment Period guide before making a change.

An appeal can be the right step when you believe an existing plan should cover a particular service, supply, or drug. A plan comparison can be useful when the issue is a broader fit problem, such as repeated network concerns, a formulary that no longer works for your medication list, or a plan that is leaving Medicare. In either case, compare the plan details relevant to your situation rather than relying on a general benefit summary.

Check that each plan serves your address, includes your doctors and hospitals, covers your medications at the needed dosage, works with your preferred pharmacy, and has cost-sharing you understand. Medicare's Plan Compare tool is a useful starting point. You can also use our Annual Enrollment Period guide and Florida Medicare Advantage switching guide to understand the main change windows.

Be especially careful if you are considering a return to Original Medicare and want a Medicare Supplement policy. A plan change does not automatically create a right to buy Medigap without underwriting. Our Florida Medigap guaranteed-issue-rights FAQ explains when specific protections may apply.

Keep a folder, paper or digital, with the following items:

Our plan-change FAQ includes a downloadable two-page checklist with a call log you can print and use during plan conversations.