Medicare Advantage Plan Denials Can Be Appealed

Medicare Advantage (MA) 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 MA plans.Medicare Advantage organizations (MAOs) 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 U.S. Department of Health and Human Services Office of the Inspector General (OIG), the three largest MAOs denied requests for long-term acute care and inpatient rehabilitation at some of the highest rates.Millions Affected by MA Plans’ Prior Authorization PoliciesAccording to KFF, 55 percent of 64.2 million Medicare beneficiaries were enrolled in MA plans in 2026. That’s up from 19 percent in 2007.MA plans use prior authorization to restrain costs by reducing unnecessary or low-value care.Nearly all MA 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 (IRFs) provide intensive therapy and medical services in a hospital environment. They serve patients with complex nursing, medical management, and rehabilitative needs.Skilled nursing facilities (SNFs) 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 (LTCHs) 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 SNF care 95 percent of the time, according to KFF.Prior authorization is rarely required for preventive services—6 percent of the time, KFF found.OIG Concerned About Prior Authorization DenialsMA plans must cover at least the same services as original Medicare. But MAOs impose additional administrative requirements, such as requiring prior authorization before certain services are allowed.The OIG found that requests for post-acute care after a qualifying hospitalization were denied even though they met Medicare coverage rules.Another OIG study showed that MAO’s 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 OIG report showed the variation in denial and overturn rates of requests for admission to IRFs and LTCHs.Medicare Advantage Organizations’ Denial RatesThe OIG studied 19 MAOs 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 LTCHs and IRFs at a higher rate than most of their peers.The three largest MAOs’ denial rates for LTCHs are:CVS Health Corporation—80 percentHumana—72 percentUnited Health Group—71 percentThe remaining 16 MAOs studied had a 42 percent denial rate.The three largest MAO denial rates for IRFs include:United Health Group—66 percentHumana—54 percentCVS Health Corporation—51 percentThe remaining MAOs’ denial rate was 41 percent.Appeal MAO Prior Authorization DenialDon’t take “no” for an answer if you or your loved one’s healthcare provider requests authorization for treatment from an MAO and it is denied.When enrollees appealed an IRF denial, MAOs collectively overturned 43 percent of these denials. LTCH denials were overturned 36 percent of the time.The OIG also found that when SNF denials were appealed, they were overturned 95 percent of the time.Many MA Enrollees Don’t Appeal DenialsMany patients don’t appeal denials. For example, the OIG found that only 18 percent of those denied SNF care actually appealed the decision.The 95 percent overturn rate of SNF care indicates that patients were initially denied medically necessary care. The OIG expressed concern for those who were denied and didn’t appeal.Appealing a DenialSome MAOs use contractors to approve or deny prior authorizations. According to the OIG, contractors like Home & Community Care, formerly known as naviHealth, have a higher denial rate than MAOs.For example, MAOs overturned 97 percent of SNF 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 an MAO, 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 planReview by an independent review entityDecision by the Office of Medicare Hearings and AppealsReview by the Medicare Appeals CouncilJudicial review in a federal district courtIf you disagree with the decision at one level, you’ll receive instructions on how to move to the next.Ensure You Appeal Any DenialsAlthough MAOs 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 MA plan as much as possible.The Epoch Times copyright © 2026. The views and opinions expressed are those of the authors. They are meant for general informational purposes only and should not be construed or interpreted as a recommendation or solicitation. The Epoch Times does not provide investment, tax, legal, financial planning, estate planning, or any other personal finance advice. The Epoch Times holds no liability for the accuracy or timeliness of the information provided.