Medicare Advantage Plans Reversed 95% of Nursing Care Denials. Only 18% Were Ever Appealed.

If a hospital, doctor, or discharge planner says a Medicare Advantage plan has denied a request for admission to a skilled nursing facility, ask for the denial in writing. Then act promptly.

If admission has been denied:

• Ask the plan for its written denial and the specific reason for the decision.
• Ask the treating physician to explain why skilled nursing or rehabilitation is medically necessary and why a less intensive level of care may not be appropriate.
• Follow the appeal instructions in the denial notice. Medicare.gov says a standard appeal for a service not yet received generally must be filed within 65 days of the date on the initial denial notice.
• If waiting could seriously jeopardize the person’s life, health, or ability to regain maximum function, ask for an expedited appeal. Medicare.gov says a fast appeal decision is generally due within 72 hours.

If approved services are being stopped:

A different process may apply when a skilled nursing facility, home health agency, or other covered provider says previously approved services will end. Look for the Notice of Medicare Non-Coverage and follow its instructions. For a fast appeal through the independent Medicare reviewer, the request generally must be made by noon on the day before the termination date listed on the notice.

These are different situations with different procedures. Read the notice carefully and contact the plan or the independent reviewer identified in it if anything is unclear.

A June 2026 report from the U.S. Department of Health and Human Services Office of Inspector General (OIG) examined requests for admission to skilled nursing facilities under 19 Medicare Advantage organizations. These facilities provide short-term skilled nursing and rehabilitation, often after a hospital stay.

Using data from June 2024, OIG found:

• 12% of admission requests were denied.
• Only 18% of those denials were appealed.
• When denials were appealed, the plans overturned 95% in favor of the enrollee.

That means approximately 82% of denials were never appealed.

The distinction matters. The report does not establish that every unappealed denial was wrong, or that every patient went without care. Some people may have received a different level of care or paid privately. But when nearly all appealed denials are overturned, the results raise a serious question: how many people accepted an initial decision that might have changed if it had been challenged?

The overall denial rate hides a striking difference between insurers.

Across the 19 Medicare Advantage organizations examined, denial rates for skilled-nursing admission requests ranged from 0.4% to 23%.

That is a substantial spread. It suggests that the results were not uniform across the industry. Differences in plan policies, review practices, contractor performance, or interpretation of coverage criteria may help explain why some organizations denied far more requests than others.

OIG recommended that the Centers for Medicare & Medicaid Services (CMS) investigate the variation and take action where warranted.

Among organizations with at least 50 appealed skilled-nursing admission denials in the OIG analysis, the reported overturn rates included:

• UnitedHealth Group: 99.7%
• CVS Health: 98.2%
• Humana: 92.1%

These figures refer to denials that were appealed—not to all admission requests, and not to all denials. They also do not prove that every initial denial was improper.

Even with those qualifications, overturn rates this high invite scrutiny of the decisions made before an appeal was filed. If a plan reverses almost every denial that is challenged, regulators have reason to examine whether the original reviews are consistently applying coverage rules correctly.

OIG found an especially large difference for people already living in nursing homes.

Requests for skilled-nursing-level care from nursing-home residents were denied 40% of the time, compared with 11% for all other enrollees—about 3.6 times the rate.

That is one of the report’s most consequential findings. But the comparison needs context.

Some Medicare Advantage organizations told OIG that nursing-home residents may be less likely to meet coverage criteria for daily skilled care. A person’s living in a nursing home does not automatically establish a need for skilled nursing or daily rehabilitation; eligibility depends on the person’s clinical circumstances and applicable coverage requirements.

That is a legitimate consideration in individual cases. It does not, by itself, explain why the denial rate was so much higher for this group. OIG recommended that CMS investigate the disparity and determine whether action is warranted.

The central question is whether the decisions reflect appropriate, individualized clinical assessments—or whether some patients are being denied based on inconsistent interpretations or review practices.

The report also examined naviHealth, a UnitedHealth Group subsidiary that processed about half of the skilled-nursing admission requests in the review.

OIG found that naviHealth denied 14% of the requests it processed, compared with 11% for plans that processed requests internally and 9% for other contractors. When patients appealed naviHealth denials, the plans overturned 97% of them.

Those findings led OIG to question whether plans were providing contractors with adequate training and oversight.

The report documents denial and appeal outcomes. It does not establish that artificial intelligence caused every denial, or that every decision was made by an algorithm. Separate reporting and scrutiny have raised concerns about the use of predictive tools in care decisions, but the OIG figures alone do not prove that AI caused the pattern it identified.

The practical issue remains the same regardless of the technology involved: plans are responsible for ensuring that coverage decisions follow Medicare rules and that their review processes work as intended.

OIG recommended that CMS:

• Address breakdowns in initial reviews that may be contributing to the very high overturn rate.
• Investigate differences in denial rates across Medicare Advantage organizations and their contractors.
• Examine the gap between nursing-home residents and other enrollees.

CMS did not explicitly agree or disagree with those recommendations in its response to the report. The recommendations call for further investigation and action as appropriate; they are not, by themselves, evidence that CMS has imposed penalties.

An earlier OIG report, published in 2022 and based on a different, broader sample of Medicare Advantage prior-authorization denials from 2019, found that 13% of sampled denials met Medicare coverage rules. That study covered different types of services and should not be treated as a direct comparison with the 2026 skilled-nursing analysis. Together, the reports show why denial decisions and appeal outcomes merit continued oversight.

The most troubling finding is not simply that Medicare Advantage plans denied some skilled-nursing admission requests. Coverage decisions sometimes turn on clinical details, and not every denial is wrong.

The concern is the combination of widely varying denial rates, a 40% denial rate for nursing-home residents, and a 95% overturn rate among appealed denials—while 82% of denials went unchallenged.

An appeal is an important safeguard, but it puts work on patients, families, doctors, and discharge planners at a time when people may already be dealing with illness, injury, or a difficult transition out of hospital care.

A fair system must make the right decision at the start as often as possible—not rely on families to discover and challenge mistakes after care has been denied.

If a Medicare Advantage plan denies a recommended admission, ask for the reason in writing, involve the treating clinician, and check the appeal instructions promptly. A denial is a decision that can be challenged, not necessarily the final word.