Medicare Advantage Plan Denials Can Be Appealed

Medicare Advantage plans, also known as Part C, are an all-in-one health insurance alternative to original Medicare. Medicare.gov says private insurance companies that contract with the federal government offer Medicare Advantage plans.

Medicare Advantage organizations require prior authorization for some medical care. According to the Center for Medicare Advocacy, these private, for-profit plans have different prior authorization requirements.

However, according to the Department of Health and Human Services Office of the Inspector General, the three largest Medicare Advantage organizations denied requests for long-term acute care and inpatient rehabilitation at some of the highest rates.

Millions Affected by Prior Authorization Policies

According to health policy nonprofit KFF, 55 percent of 64.2 million Medicare beneficiaries were enrolled in Medicare Advantage plans in 2026. That’s up from 19 percent in 2007.

Medicare Advantage plans use prior authorization to restrain costs by reducing unnecessary or low-value care.

Nearly all Medicare Advantage enrollees, or 99 percent, according to KFF, are in plans that require prior authorization for certain services. Traditional Medicare rarely uses such authorization.

There are three services that prior authorization may affect:

• Inpatient rehabilitation facilities provide intensive therapy and medical services in a hospital environment. They serve patients with complex nursing, medical management, and rehabilitative needs.

• Skilled nursing facilities provide therapy or nursing services to patients rehabilitating after inpatient hospital stays. This could be for issues such as joint replacement or stroke.

• Long-term care hospitals offer acute care to patients who need hospital-level care for an extended period. Treatment could include respiratory therapy, head trauma treatment, and pain management.

Prior authorization is typically required for these relatively expensive services, and affects acute inpatient care 97 percent of the time, inpatient psychiatric care 93 percent of the time, and skilled nursing facility care 95 percent of the time, according to KFF.

Prior authorization is rarely required for preventive services—6 percent of the time, KFF found.

Inspector General Concern

Medicare Advantage plans must cover at least the same services as original Medicare. But Medicare Advantage organizations impose additional administrative requirements, such as requiring prior authorization before certain services are allowed.

The Office of the Inspector General found that requests for post-acute care after a qualifying hospitalization were denied even though they met Medicare coverage rules.

Another Inspector General study showed that Medicare Advantage organizations’ use of prior authorization often resulted in denials and delays to access needed care.

Denials of post-acute care requests after a hospital stay were identified as a particular concern. The Inspector General report showed the variation in denial and overturn rates of requests for admission to inpatient rehabilitation facilities and long-term care hospitals.

Medicare Advantage Organizations’ Denial Rates

The Inspector General studied 19 Medicare Advantage organizations to determine denial rates for post-acute care after a hospital stay. They found that in 2024, the three largest MAOs by enrollment denied authorization requests for care in long-term care hospitals and inpatient rehabilitation facilities at a higher rate than most of their peers.

The three largest Medicare Advantage organizations’ denial rates for long-term care hospitals are:

• CVS Health Corporation—80 percent

• Humana—72 percent

• United Health Group—71 percent

The remaining 16 Medicare Advantage organizations studied had a 42 percent denial rate.

The three largest Medicare Advantage organizations denial rates for inpatient rehabilitation facilities include:

• United Health Group—66 percent

• Humana—54 percent

• CVS Health Corporation—51 percent

The remaining Medicare Advantage organizations’ denial rate was 41 percent.

Appeal Prior Authorization Denial

Don’t take “no” for an answer if you or your loved one’s healthcare provider requests authorization for treatment from an Medicare Advantage organization and it is denied.

When enrollees appealed an inpatient rehabilitation facilities denial, Medicare Advantage organizations collectively overturned 43 percent of these denials. Long-term care hospital denials were overturned 36 percent of the time.

The Inspector General also found that when skilled nursing facility denials were appealed, they were overturned 95 percent of the time.

Many Medicare Advantage Enrollees Don’t Appeal Denials

Many patients don’t appeal denials. For example, the Inspector General found that only 18 percent of those denied skilled nursing facility care actually appealed the decision.

The 95 percent overturn rate of skilled nursing facility care indicates that patients were initially denied medically necessary care. The Inspector General expressed concern for those who were denied and didn’t appeal.

Appealing a Denial

Some Medicare Advantage organizations use contractors to approve or deny prior authorizations. According to the Inspector General, contractors like Home & Community Care, formerly known as naviHealth, have a higher denial rate than MAOs.

For example, Medicare Advantage organizations overturned 97 percent of skilled nursing facility denials issued by naviHealth when patients appealed. NaviHealth is a subsidiary of Optum.

According to Medicare.gov, you have the right to ask your plan to provide or pay for items or services you think it should cover, provide, or continue. You can also ask for an appeal to resolve differences with your plan.

It starts with your healthcare provider. If you have been denied care by a Medicare Advantage organization, discuss this with your healthcare provider. They can have a peer-to-peer discussion with the MAO’s doctor to plead your case. This may be the only step you need to take. There are five levels of appeal.

• Reconsideration from your plan

• Review by an independent review entity

• Decision by the Office of Medicare Hearings and Appeals

• Review by the Medicare Appeals Council

• Judicial review in a federal district court

If you disagree with the decision at one level, you’ll receive instructions on how to move to the next.

Ensure You Appeal Any Denials

Although Medicare Advantage organizations approve most requests and services, they also issue millions of denials each year.

However, you have rights. Work with your healthcare provider to appeal any denials so you can receive the care you need through your Medicare Advantage plan as much as possible.

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