Goodsurance

Medicare Advantage

When Medicare Advantage Patients Appealed Nursing Home Denials, Plans Reversed the Decision 95 Percent of the Time

A federal watchdog reviewed prior authorization denials for skilled nursing facility admission across 19 Medicare Advantage insurers and found most initial denials were overturned. The concern: only about one in six denied patients ever appealed.

By the Goodsurance editorial teamAugust 25, 2026

When Medicare Advantage enrollees or their providers challenged a denial for skilled nursing facility admission, the insurer sided with the patient 95 percent of the time, according to a report published June 11, 2026, by the HHS Office of Inspector General.

The audit examined prior authorization data from 19 Medicare Advantage organizations during June 2024. Those plans collectively denied 12 percent of all requests for skilled nursing facility admission, though denial rates ranged from just under half a percent at the most permissive plan to 23 percent at the most restrictive.

Nursing home residents seeking a higher level of skilled care faced a steeper hurdle. Their requests were denied 40 percent of the time, compared with 11 percent for other enrollees.

The contractor naviHealth processed roughly half of all skilled nursing requests reviewed and denied 14 percent of them, a higher rate than plans that handled requests internally or through other contractors. When patients appealed naviHealth decisions, plans reversed 97 percent of those denials.

The OIG concluded that the high overturn rate raises serious questions about whether many initial denials were appropriate in the first place. Only about 18 percent of patients who were denied actually filed an appeal, leaving the watchdog concerned about those who accepted the denial and went without care.

The report recommended that CMS strengthen oversight of prior authorization contractors and track denial and overturn rates more closely. Prior authorization for skilled nursing facility stays is now required by approximately 95 percent of Medicare Advantage plans, which collectively cover more than 33 million people.

In plain words

When Medicare Advantage plans said no to nursing home care, they almost always changed their minds when someone pushed back. A government report found that 95 out of every 100 denied nursing home requests were approved after an appeal. The problem is that most people never file an appeal. Only about 1 in 6 people who were denied actually tried.

The report also found that denial rates varied a lot from plan to plan, from less than 1 percent to 23 percent. Nursing home residents who needed more intensive care were denied much more often than other patients, 40 percent of the time versus 11 percent for others.

If your Medicare Advantage plan denies skilled nursing care, federal rules give you the right to appeal. The data show that appeals have a very strong track record.

Understand the basics first

Source: OIG
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