Policy & oversight
Medicare Advantage Plans Reversed 95 Percent of Appealed Nursing Home Admission Denials, OIG Reports
A June 2026 Office of Inspector General report found that Medicare Advantage organizations overturned nearly all appealed prior authorization denials for skilled nursing facility admission, and that residents already living in nursing homes were denied at four times the rate of other enrollees.
By the Goodsurance editorial teamJuly 7, 2026
Medicare Advantage organizations collectively denied 12 percent of prior authorization requests for skilled nursing facility admission in June 2024 and later overturned 95 percent of those decisions when patients or providers appealed, according to a report from the Office of Inspector General published June 11, 2026.
The overturn rate indicates that a substantial share of initial denials were not clinically appropriate, the OIG concluded. Only 18 percent of denials were ultimately appealed, leaving the agency concerned that many patients who did not challenge a decision may have forgone care they were entitled to receive.
Medicare Advantage reversed 95 percent of appealed nursing home admission denials. Residents already in nursing homes were denied four times as often as other patients.
The data revealed a sharp disparity by patient setting. Plans denied skilled nursing facility requests from people already residing in nursing homes 40 percent of the time, compared with 11 percent for all other enrollees, a nearly fourfold difference the OIG said warrants further examination.
Third-party contractors also played a notable role. The contractor naviHealth processed approximately half of all skilled nursing facility prior authorization requests and denied 14 percent, a higher rate than plans that handled reviews internally. When naviHealth denials were appealed, they were overturned 97 percent of the time.
The OIG recommended that CMS collect more detailed request-level prior authorization data by service type and contractor, and address what it described as a breakdown in the quality of initial review decisions for skilled nursing facility admissions. Skilled nursing facilities provide short-term rehabilitation and nursing services, often immediately following a hospital stay.
In plain words
A federal watchdog found that when Medicare Advantage plans said no to nursing home care, they changed their mind 95 times out of 100 when patients or doctors pushed back. That raises questions about whether the first decisions were correct. People who were already living in nursing homes had a much harder time: plans said no to them 40 percent of the time, versus 11 percent for everyone else. A contractor called naviHealth handled half of all these requests and also had a high denial rate, with 97 percent of its denials overturned when people appealed. Many patients never appealed and may have missed care they were owed.
Understand the basics first
Source: OIG
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