Medicare Advantage Plans Reversed 95 Percent of Appealed Nursing Home Admission Denials, OIG Reports

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.

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.