How a Medicare Advantage plan has to decide your request
Checked against the current rules on September 18, 2026.
Before there's anything to appeal, the plan has to make an initial decision — called an organization determination. That first decision has its own rules about how it's made and how you're told about it.
Source: 42 CFR Part 422, Subpart M — Grievances, Organization Determinations and Appeals.
An organization determination is the plan's decision on whether to cover a service, item, or drug, or whether to pay a claim for one already provided. This is the decision an appeal challenges — it's the starting point of the whole process.42 CFR 422.566
A request can come from the enrollee, a representative acting on their behalf, or — for a service not yet provided — the treating physician asking on the patient's behalf. The plan can't require the request to come through any one specific channel only.
The plan has to give you a written notice of its determination that states the reason and, if it's a denial, explains your right to appeal and how to do it.42 CFR 422.568
What this means for your appeal
If the denial notice you received doesn't clearly state a reason, or doesn't explain how to appeal, that's itself worth raising — the plan is required to include both, not just a bare "denied" stamp.
Knowing this is the FIRST decision, not the final word, matters: an organization determination is exactly what a reconsideration (Level 1 appeal) exists to challenge, and the plan is required to take a fresh, independent look at it.
An organization determination can be a full denial, a partial approval (covering some but not all of what was requested), or an approval with conditions — each of these is appealable, not just an outright "no." A partial approval that doesn't cover everything the treating physician actually ordered is still worth appealing for the difference.
Requesting the determination in writing, and keeping a copy of exactly what was asked for, makes it easier to spot when a plan's later denial notice doesn't match the original request — a mismatch that's itself worth raising on appeal.
This is also the point where an expedited request can be made, when the standard timeframe could seriously jeopardize the patient's health — asking for expedited handling at this first stage, rather than only later, can save real time.
Sources — last checked September 18, 2026
- 42 CFR 422.566as of September 18, 2026
- 42 CFR 422.568as of September 18, 2026
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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.
