If you had a nine in ten chance of winning something, wouldn’t you would go for it? Those are odds worth taking. What if it was not only something you wanted, but something you needed, like medically necessary services in a skilled nursing facility?
This is the situation many older adults and people with disabilities find themselves in if they are enrolled in a Medicare Advantage plan. These plans offer a way to receive Medicare benefits through private insurance companies, rather than directly from the federal government. Medicare Advantage plans require “prior authorization” (pre-approval) before they will cover many services. In theory, prior authorization prevents unnecessary, costly care. In practice, doctors and patients say that it has become overused and burdensome, causing delays and denials of care that patients need.
When a Medicare Advantage plan denies prior authorization, the patient has a right to appeal. It is important to understand and make use of this appeal right, because plan denials are frequently overturned. A new federal report examined nursing facility care specifically, and its findings show just how often these pre-approval denials are wrong.
The June 2026 report from the U.S. Department of Health and Human Services’ Office of Inspector General found that when patients and providers appeal Medicare Advantage denials of prior authorizations for nursing facility care, they win 95% of the time. Skilled nursing facility care, which includes physical and occupational therapy as well as nursing, helps bridge the gap between a hospital discharge and the ability to return home with as much independence as possible. Given how often denials are overturned — and how critical these services are — appealing is clearly worthwhile.
Every written denial notice from a Medicare Advantage plan must explain how to appeal, and patients can also ask their healthcare provider to support the appeal with medical documentation. Because appeals have deadlines, it is important to act promptly and ask for help if you need it. Many appeals succeed because additional information shows that the requested care meets Medicare’s coverage rules.
But most Medicare Advantage denials are not appealed. The federal analysis found that only 18% of initial denials for nursing facility care were appealed, for example. As the report notes, the “extremely high overturn rate indicates that some enrollees were initially denied medically necessary care,” and it “raises concerns about denials that were not appealed.”
Why do Medicare Advantage plans deny coverage so frequently? The federal watchdog report points to profit incentives for the plans. These plans are paid a fixed monthly amount per patient, regardless of how many services that person receives. The report flags this as “a central concern” for denials of care. Every denial that is not appealed can save money for the plan.
The result is predictable: Medicare Advantage plans deny, and many people who could receive coverage never appeal. They may not understand that they have the right to appeal, or they assume an appeal will not be successful, or they are simply overwhelmed by the bureaucratic hurdles involved. Research shows that these barriers discourage patients from pursing healthcare benefits. As a result, patients may opt for cheaper, less effective care, pay out of pocket, or go without needed care altogether. These concerns are heightened for the older adults and disabled individuals who rely on Medicare for health coverage.
The good news is that Massachusetts Medicare beneficiaries can get help with Medicare Advantage denials, and more, by reaching out to the Medicare Advocacy Project (MAP). MAP’s experienced advocates provide free legal assistance for Medicare-related issues. In central and western Massachusetts, MAP can be reached via Community Legal Aid, which provides free civil legal assistance to older adults and low-income individuals. We encourage anyone facing a Medicare denial or appeal to apply for assistance through our website, www.communitylegal.org, or through our intake line, 855-252-5342.
Reform is needed to fix a system that gets it wrong far too often. Older adults and people with disabilities should not have to fight so hard for nursing facility services and other medical care they need and qualify for by law. U.S. taxpayers should expect Medicare Advantage plans to deliver the healthcare they pay those plans to provide.
But for now, the takeaway is simple. If a Medicare Advantage plan denies your prior authorization request, don’t assume the answer is final. Read the denial notice, pay attention to deadlines, and ask for help if you need it. Given the odds, an appeal may make all the difference.
Alice Bers is director of the Massachusetts Medicare Advocacy Project.