Medicare Advantage denied it, but the LCD covers it: how to appeal

Updated October 2026 · Not legal advice. Rules change, so check deadlines and requirements against current CMS guidance, 42 CFR Part 422, and the plan's denial notice before you file.

A Medicare Advantage (MA) plan can't make up its own coverage rules when traditional Medicare already has one. Under 42 CFR 422.101(b), MA plans must follow national coverage determinations (NCDs), traditional Medicare's general coverage rules, and the local coverage determinations (LCDs) of the Medicare contractors where the plan operates. Under 422.101(b)(6), added by the 2024 MA rule (CMS-4201-F, effective January 1, 2024), a plan may use its own internal criteria only when Medicare's criteria are "not fully established." Even then, the plan must publish those criteria along with its evidence summary, its sources and its rationale.

Appeals of these denials are worth filing. KFF found that MA plans fully or partly denied 4.1 million prior-authorization requests in 2024. Only 11.5% of those denials were appealed, and 80.7% of appeals were fully or partly overturned (KFF, Jan. 28, 2026). The overturn figure includes partial reversals, and some of those wins came from adding documentation that was missing the first time. In a 2019 sample, HHS-OIG found that 13% of MA prior-auth denials met Medicare coverage rules (OIG OEI-09-18-00260, Apr. 2022).

Here's how to turn "the LCD covers this" into a reconsideration request.

Step 1: Read the denial notice closely

Write down four things:

The notice date.
Whether it is pre-service (the item hasn't been delivered yet) or a payment denial.
Whether it was expedited.
The exact reason the plan gave. MA denial notices must "state the specific reasons for the denial" (422.568(e)(2)). Quote that reason word for word in your letter.

Step 2: Confirm who can file

The enrollee can always file.
A representative can file with a signed CMS-1696 Appointment of Representative.
The treating physician can request a standard pre-service reconsideration after giving notice to the enrollee, and can also request an expedited one.
A non-contract supplier can appeal a payment denial only after signing a Waiver of Liability, which says it won't bill the enrollee whatever the outcome. Without the waiver, the request may be dismissed.
In-network (contract) providers generally take their own payment disputes through the plan's contract dispute process instead. Check the plan's provider manual.

Step 3: Find the governing rule and note its version

Look up the code in the CMS Medicare Coverage Database. For DME, pull three things:

the LCD;
its policy article, which holds the ICD-10 lists and coding rules;
any NCD.

The major DME LCDs, including the CPAP, oxygen, CGM, power mobility and hospital bed LCDs, are adopted identically by both DME MACs across all four jurisdictions. Write down the revision number and effective date, and check that the revision was in effect on the date of the request or delivery.

Step 4: Decide which kind of denial you have

Kind A: the plan applied a stricter rule than the LCD. Examples are a higher threshold, an extra test, or a requirement the LCD doesn't contain. This is the 422.101(b)(6) argument.
Kind B: the plan says documentation is missing. Check the record against the LCD's documentation list. If something really is missing, get it before you appeal. A regulatory argument won't fix an empty chart. OIG also found "insufficient documentation" denials where the records were in fact sufficient, so check before you accept that reason.

Step 5: Map every criterion to the evidence

Make a two-column list. On the left, put each LCD criterion. On the right, put the dated record that meets it, with a page reference to your enclosures. This map is the core of the letter.

Worked example: CPAP (E0601) under LCD L33718

Fictional case for illustration.

An MA plan denies a pre-service request for E0601 (CPAP device). The stated reason is: "Sleep study AHI of 11 does not meet plan criteria requiring AHI of 15 or greater."

The governing rules are:

LCD L33718, Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (R11, effective Jan. 1, 2024);
policy article A52467, which lists G47.33 as the supporting diagnosis;
NCD 240.4.

L33718 covers an initial 12-week trial when all of these are met:

L33718 criterion	Evidence in this record
In-person clinical evaluation by the treating practitioner before the sleep test	Office note dated [date], before the test, with sleep history, Epworth score, neck circumference and BMI
A Medicare-covered sleep test (facility PSG, or home/inpatient Type II, III, IV or Other) showing either AHI/RDI of 15 or more with at least 30 events, or AHI/RDI of 5–14 with at least 10 events plus a documented qualifying symptom or comorbidity (excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, hypertension, ischemic heart disease or history of stroke)	Home sleep test (Type III): AHI 11/hr, 52 events. Hypertension documented in the problem list and visit notes
The supplier instructs the beneficiary or caregiver on use and care	Will be documented at setup

The patient meets the LCD's second pathway. The plan's "AHI of 15 or greater" requirement is stricter than L33718. Because the LCD sets the criteria in full, they are not "not fully established," so (b)(6) doesn't allow the plan to substitute its own.

Plan ahead for continued coverage after the trial. You'll need an in-person re-evaluation between day 31 and day 91 that documents benefit. You'll also need adherence data showing use of at least 4 hours per night on 70% of nights during a consecutive 30-day period within the first 3 months.

Step 6: Write the letter

Include these, in this order:

Identifiers: the plan's appeals address from the notice; the enrollee's name, member ID and date of birth; the authorization or claim number; the provider's NPI and TIN; a contact person.
Subject line: "Request for [Expedited] Reconsideration of Organization Determination [ref #]."
What was denied: the HCPCS and ICD-10 codes, the dates, and the plan's reason, quoted.
Your standing: attach the CMS-1696 or Waiver of Liability if needed.
The request: reverse the denial in full.
The governing rule: the LCD number, title and revision, the article and the NCD.
Your criterion-by-criterion map from Step 5.
The regulation: 422.101(b) requires the plan to follow the LCD. Under (b)(6), internal criteria are allowed only when Medicare's criteria are not fully established, and here they are fully established. Under 422.101(c)(1)(i), the decision must take into account the enrollee's medical history and the treating physician's recommendation.
If the plan used internal criteria: ask it to identify them and say where the publicly posted criteria, evidence summary and rationale can be found.
The reviewer: ask for confirmation that the reconsideration will be made by a physician with appropriate expertise who was not involved in the original decision (422.590(h)).
If the item was already authorized: cite 422.138(c).
Enclosures and signature.

Step 7: File on time and calendar the plan's deadline

	Deadline
You file the reconsideration	60 calendar days after you receive the notice. Receipt is presumed 5 days after the notice date. To be safe, count 60 days from the notice date.
Plan decides: standard pre-service	30 calendar days
Plan decides: payment	60 calendar days
Plan decides: expedited (pre-service only, when a physician says the standard timeframe could seriously jeopardize the enrollee's life, health or ability to regain maximum function)	72 hours

For services, the plan can extend these deadlines by up to 14 days. If the plan upholds its denial in whole or in part, it must forward the case automatically to the Independent Review Entity, so you don't need to file anything for that step. If the plan misses its deadline, that counts as upholding the denial.

Common mistakes

Citing the wrong version. An outdated LCD revision, or the LCD without its policy article, gives the plan an easy reason to say no.
Arguing the rule when the record is the problem. If an element is really missing, fix the record first.
A generic "medically necessary" letter. Map every criterion to evidence.
Filing without standing. A missing CMS-1696 or Waiver of Liability can get the request dismissed.
Missing the 60-day window. Calendar it the day the notice arrives.
Treating peer-to-peer as a right. No MA regulation grants one, and some plans drop peer-to-peer once a denial is issued. Make sure the written appeal can stand on its own.
Pasting PHI into tools that haven't signed a BAA with you.

ClinicalCodes is building a ClinicalCodes appeal kit for MA denials of DME items such as CPAP, home oxygen, CGMs, power wheelchairs and hospital beds. You enter the code and the denial reason, and the kit returns the governing LCD with its version, a documentation checklist and a draft letter like the one above. If you'd like early access, join the waitlist.

Not legal advice. This guide is educational and does not determine coverage for any claim. ClinicalCodes is not affiliated with CMS.