What to Do If Your Medicare Advantage Plan Denies Rehab

Takeaways

• A Medicare Advantage denial of post-acute care is not necessarily final.

• Ask for the denial in writing and follow the appeal instructions on the notice.

• Your doctor, hospital discharge planner, and receiving facility may be able to provide supporting medical records.

• Ask for an expedited appeal if waiting could seriously harm your health or ability to recover.

• Medicare Advantage plans have overturned a substantial share of appealed post-acute care denials.

If you have Medicare Advantage and have recently been hospitalized, a doctor may say you need more care after leaving the hospital, whether at an inpatient rehabilitation facility or rehabilitation center, skilled nursing facility, or long-term care hospital. But what if your Medicare Advantage plan says no?

Federal investigators have been examining how often Medicare Advantage plans deny this kind of post-acute care. What they’ve found raises real concerns for the more than half of Medicare-eligible beneficiaries now enrolled in these private plans.

In June 2026, the Department of Health and Human Services’ Office of Inspector General (OIG) published two reports examining prior authorization requests, the advance approval many Medicare Advantage plans require before they’ll pay for care.

Among the 19 Medicare Advantage organizations reviewed, nearly two-thirds of prior authorization requests for long-term care hospital stays were denied. Over half of requests for inpatient rehabilitation facility stays were also denied. Requests for skilled nursing care were denied about 12 percent of the time. These denial rates are well above the roughly 8 percent overall Medicare Advantage prior authorization denial rates for all types of care combined.

A denial is not necessarily final. When patients appealed, Medicare Advantage organizations overturned 36 percent of long-term care hospital denials, 43 percent of inpatient rehabilitation denials, and 95 percent of skilled nursing facility denials. 

These findings suggest that some people may have been denied medically necessary care initially, but relatively few denials were ever appealed.

Why Medicare Advantage Plans Deny This Kind of Care

Post-acute care is health care you need after a hospital stay. It may include physical therapy, wound care, rehabilitation services, or skilled nursing, and it tends to be expensive. It’s also an area where prior authorization can create an additional review step before care is approved.

A few factors help explain the pattern investigators found:

• How Medicare Advantage plans get paid. Because Medicare Advantage plans receive fixed monthly payment for each enrollee, denying or limiting covered care can reduce the plan’s spending on that enrollee. This payment structure, on its own, doesn’t prove wrongdoing, but investigators have flagged it as a potential financial incentive to deny expensive services like extended rehab or long-term hospital stays.

• Reliance on outside contractors. Some of the highest denial rates were traced to outside contractors that review requests on a plan’s behalf, sometimes using automated tools to help make decisions quickly. OIG found that a meaningful share of those contractor-driven denials were later overturned by the plan on appeal, raising questions about whether the contractors were adequately trained or supervised.

• Wide variation between insurers. Denial rates varied enormously depending on which company administered a patient’s plan. That variation suggests the differences are more about a given insurer’s internal policies and review practices than about any objective difference in how sick their members are.

• Low appeal rates create little pushback. Because relatively few denied patients file an appeal, plans may face limited pressure to correct a pattern of overly strict initial reviews, even when a large share of appealed cases are ultimately reversed.

Insurers have pushed back on some of these findings, arguing that prior authorization is a legitimate tool to ensure care is medically necessary and to guard against unnecessary costs that could raise premiums for everyone. Federal regulators and members of Congress from both parties, however, have said the scale and inconsistency of these denials warrant closer scrutiny.

What to Do If Your Care Is Denied

A denial is not necessarily the final word. Medicare Advantage enrollees have the right to challenge denials, and appeals succeed often enough that it’s worth trying. Here’s how to respond if you’re facing a denial for post-acute care.

Get the Denial in Writing 

Ask for the written denial notice if you haven’t received it. It should explain the reason for the denial and how to appeal. Keep copies of the denial notice, any letters from the facility, and notes from phone calls, including dates, names of the people you spoke with, and what was said.

Ask Your Doctor or Facility for Help Building Your Case

Your hospital discharge planner, doctor, or a staff member at the receiving facility can be a valuable ally. They often have experience navigating these denials and can help identify what documentation the plan says is insufficient or missing. Ask them directly:

• What specific medical criteria did the plan say I didn’t meet?

• What additional records, test results, or physician notes could address that gap?

• Can you write a letter of medical necessity explaining why this level of care is required?

• Is there a case manager or patient advocate at this facility who handles insurance appeals?

File an Appeal

Every Medicare Advantage plan must have an appeals process. The first level is called reconsideration. 

Some key things to know:

• Deadlines matter. You typically have 65 days from the date of the plan’s initial denial notice to request reconsideration, but follow the deadline and instructions on your notice. A standard service appeal generally must be decided within 30 days.

• If waiting could jeopardize your health, ask for an expedited appeal. It generally must be decided within 72 hours.

• If the plan upholds its denial, it must forward your case to an independent outside reviewer for a second look. You don’t have to request this separately.

• Your doctor can request an appeal on your behalf, which can carry weight since the reviewer will be evaluating medical necessity.

For a broader explanation of Medicare’s five-level appeal process, read this related article.

Get Free, Expert Help

Every state has a State Health Insurance Assistance Program (SHIP), which offers free, unbiased counseling on Medicare appeals. You can also contact Medicare at 1-800-MEDICARE or reach out to a local aging or disability advocacy organization, many of which have staff who specialize in Medicare Advantage appeals and denials.

Keep a Record of the Effects of Any Delay

If the denial is delaying your discharge or forcing you to leave a facility before you or your family feel it’s safe, document that too. Notes on your condition, mobility, and complications may support your appeal.

A Medicare Advantage Denial Is Not Necessarily Final

Federal data suggest that a substantial share of Medicare Advantage denials for post-acute care may not hold up to scrutiny. That doesn’t mean every denial is wrong. However, it does mean patients and families have real reason to push back. Getting the denial in writing, asking your care team for documentation, and filing a timely appeal are the best paths to getting a second look — and, quite possibly, a different outcome.