Medicare Advantage denied imaging or a procedure? What the rule says and how to appeal.
Checked against the current rules on September 18, 2026.
A denial for imaging or a procedure isn't the end of the story — Medicare Advantage plans have to follow specific coverage rules, and a denial that doesn't square with those rules is exactly the kind of appeal that tends to win.
Here's what the rule actually requires, what evidence usually turns a denial around, and the deadline you're working against.
What the rule requires
Coverage for imaging or a procedure under a Medicare Advantage plan is governed by§ 422.101 Requirements relating to basic benefits.. A Medicare Advantage plan generally cannot apply a stricter test than what these rules require.
Questions that decide it
Before you appeal, these are the facts that usually decide whether a denial like this holds up:
Did the denial cite a specific rule or guideline it used, or just say "not medically necessary" with no source?
Did the denial mention the plan's own internal coverage policy rather than a Medicare NCD or LCD?
Has anyone asked the plan, in writing, for a copy of the specific guideline it used?
What a winning appeal has to show
An appeal that wins usually includes:
The ordering physician's note stating the clinical basis for the imaging/procedure — Establishes medical necessity under whatever the actual governing NCD/LCD criteria are. (Your doctor's office provides this.)42 CFR 422.101
The denial letter's own stated basis (a specific NCD/LCD, or the plan's own criteria) — Determines whether §422.101(b)(1)-(3)'s Traditional Medicare criteria or §422.101(b)(6)'s internal-criteria rules apply. (Request this from the plan.)42 CFR 422.101
A copy of the plan's own internal criteria, if requested and provided — §422.101(b)(6) requires internal criteria be publicly accessible on request. (Request this from the plan.)42 CFR 422.101
Your deadline to appeal
65 days from the date on the notice. The rule (42 CFR § 422.582) gives you 60 days from when you receive the denial, and receipt is presumed to be 5 days after the notice's own date unless shown otherwise — 60 + 5 = 65 days from the notice date.42 CFR 422.582
The plan itself then has its own clock to decide. The plan must decide within 30 calendar days for a request about a service you haven't received yet, 60 calendar days for a request about payment for something already provided, or 72 hours if the request is expedited (42 CFR § 422.590).
What to ask your doctor to address
If you're asking the treating physician for a supporting letter, it should speak to:
The clinical basis for ordering the imaging or procedure.42 CFR 422.101
Why alternative, already-covered approaches weren't sufficient, if relevant.42 CFR 422.101
Questions people ask
- Can the plan just say it's "not medically necessary" with no further explanation?
- The denial notice has to explain the basis for the decision and tell you how to appeal. If it doesn't point to a specific rule or criteria, that's itself worth raising in your appeal — you're entitled to know what standard was applied.
- What if I don't have all the evidence listed above?
- Include what you have. An appeal with partial evidence and a clear explanation of the rule still gets a real review — it doesn't need to be complete to be worth filing.
Sources — last checked September 18, 2026
- § 422.101 Requirements relating to basic benefits.as of September 18, 2026
- 42 CFR 422.582as of September 18, 2026
Related
Not sure what applies to your case?
Upload your denial letter and get a free, plain-language explanation with your real deadline.
By CaseWhy Appeals editorial. See how this content is produced. Not legal advice. Not affiliated with or endorsed by Medicare, CMS, or any health plan. A product of CaseWhy LLC.
