Medicare Advantage denied a Part B drug? What the rule says and how to appeal.
Checked against the current rules on September 18, 2026.
A denial for a Part B drug 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 a Part B drug under a Medicare Advantage plan is governed by§ 422.568 Standard timeframes and notice requirements for organization determinations.. 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:
About how many days after the request did the plan actually respond?
Did the plan ask the prescribing doctor's office for more information, and was that request answered?
Was this request marked urgent/expedited, or handled as a standard request?
What a winning appeal has to show
An appeal that wins usually includes:
A record of when the coverage-determination request was made (fax confirmation, portal timestamp, call log) — §422.568's 7/14-day clock runs from when the plan actually received the request. (You or your family provide this.)42 CFR 422.568
The date the plan actually responded, if any — Establishes whether the plan's own deadline was missed. (Request this from the plan.)42 CFR 422.568
Documentation that expedited handling was requested, if applicable — Expedited requests carry a shorter timeframe. (You or your family provide this.)42 CFR 422.568
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 diagnosis and reason the Part B drug was prescribed.42 CFR 422.568
Whether delaying the drug could seriously jeopardize the patient's health, supporting an expedited request.42 CFR 422.568
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
- § 422.568 Standard timeframes and notice requirements for organization determinations.as of September 18, 2026
- 42 CFR 422.582as of September 18, 2026
Related
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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.
