Medicare Advantage Denied Skilled Nursing? How to Appeal
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Key takeaways
- A Medicare Advantage plan's refusal to approve or pay for skilled nursing facility care can be appealed, and a fast decision is due within 72 hours when a doctor says waiting could seriously harm the patient's health.
- Federal rules say Medicare Advantage plans must follow Traditional Medicare's coverage requirements for skilled nursing facility care, unless laws for Medicare Advantage plans say otherwise, and may use their own criteria only where Medicare's are not fully established.
- A Level 1 appeal must be filed within 60 days of receiving the denial (Medicare.gov says 65 days from the date on the notice). If the plan keeps its denial, the case goes to an independent reviewer automatically.
- When a plan ends a covered stay, the nursing home must give a Notice of Medicare Non-Coverage at least 2 days ahead, and a fast-track appeal goes to the BFCC-QIO by noon of the day after the notice is delivered.
- In a June 2026 report, the HHS Office of Inspector General found that when denials of skilled nursing facility admission requests from June 2024 were appealed, the 19 Medicare Advantage organizations it reviewed overturned 95 percent in the enrollee's favor.
Short answer
Yes, a Medicare Advantage plan's denial of skilled nursing facility (rehab) care can be appealed. If the plan refuses to approve admission, federal rules let the patient or a representative ask the plan to reconsider (in some cases a doctor can ask too), and a fast decision is due within 72 hours when waiting could seriously harm health. If the plan is ending a covered stay, the nursing home must give a written notice, and a fast-track appeal goes to an independent reviewer called the BFCC-QIO.
What the notice and the rules say to check
- The date and deadline on the notice. A denial must be in writing, give the specific reasons and explain how to appeal. The notice shows the date it was issued; Level 1 appeal requests are due within 60 days of receiving it (Medicare.gov says 65 days from the date on the notice). A notice that coverage is ending has its own, much shorter deadline (see Situation B).
- Fast (expedited) decisions. A fast decision is available when waiting could seriously harm health, and any doctor can ask for one or support it. If a doctor says the standard timeline could seriously jeopardize the patient's life, health or ability to regain maximum function, the plan must give a fast decision.
- Free help. State Health Insurance Assistance Programs (SHIPs) give free Medicare counseling, including help with appeals; the local SHIP can be found at shiphelp.org or by calling 1-877-839-2675. 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048) also answers questions.
There are two situations with different steps: A, the plan will not approve admission, and B, the plan is ending a covered stay.
Does a Medicare Advantage plan have to follow Medicare's rehab rules?
Yes. Federal rules (42 CFR § 422.101(b)(2)) say Medicare Advantage plans must follow the general coverage and benefit conditions in Traditional Medicare laws, unless laws for Medicare Advantage plans say otherwise, and these expressly include the requirements for payment of skilled nursing facility care in 42 CFR part 409. A plan may use its own internal criteria only when Medicare's coverage criteria are not fully established, and it must make those criteria public, with a summary of the evidence and its reasons.
Medical necessity decisions must be based on Medicare's coverage criteria and on the patient's medical history, the doctor's recommendations and clinical notes. In its final rule for contract year 2024 (published April 2023), CMS explained that when a patient being discharged from a hospital has an attending physician's order for skilled nursing facility care because daily skilled care in an institution is needed, the plan cannot deny that care and send the patient to home health instead unless the patient does not meet Medicare's skilled nursing facility coverage criteria. Plans may also choose to cover skilled nursing facility care without the 3-day hospital stay that Original Medicare requires. For the basic Medicare rules, see what Medicare covers in a nursing home.
How often are Medicare Advantage rehab denials overturned?
In a June 2026 report, the HHS Office of Inspector General (OIG) found that in June 2024 the 19 Medicare Advantage organizations it reviewed denied 12 percent of requests for skilled nursing facility admission. Denial rates ranged from 0.4 percent to 23 percent across those organizations. Enrollees and their providers appealed 18 percent of the denials, and when they did, the organizations overturned 95 percent in the enrollee's favor.
Situation A: the plan denied admission to a skilled nursing facility
When the plan refuses to approve or pay for skilled nursing facility care, federal rules call this an "organization determination," and it can be appealed. CMS's standard denial notice is the Notice of Denial of Medical Coverage or Payment (form CMS-10003-NDMCP).
| Step | Who decides | Time limit |
|---|---|---|
| Coverage request | The plan | Fast: 72 hours. Standard: 14 days, or 7 days for services under prior-authorization rules (from 2026) |
| Level 1: reconsideration | The plan (a doctor not involved before, for medical necessity) | File within 60 days of getting the notice. Decision: fast 72 hours; standard 30 days |
| Level 2: independent review | Independent Review Entity | Automatic if the plan keeps its denial |
| Level 3: hearing | Administrative Law Judge | Ask within 60 days; 2026 minimum amount $200 |
| Level 4 | Medicare Appeals Council | Ask within 60 days of the judge's decision |
| Level 5 | Federal district court | Ask within 60 days of the Council's decision; 2026 minimum amount $1,960 |
The coverage decision. Federal rules give the plan 14 calendar days for a standard decision. Starting in 2026, the limit is 7 calendar days for a service that falls under the plan's prior-authorization rules. A fast decision is due within 72 hours. The plan may add up to 14 days only in listed cases, such as when the enrollee asks, and it must explain the delay in writing. If the plan does not decide on time, that failure itself counts as a denial that can be appealed.
If the plan refuses to expedite. The plan must move the request to the standard timeline and send a letter within 3 calendar days explaining the right to a fast complaint (expedited grievance), which it must answer within 24 hours.
Level 1 appeal (reconsideration). Federal rules say the appeal must be filed within 60 calendar days after receiving the written denial, and receipt is presumed 5 days after the notice date. Medicare.gov states this as 65 days from the date on the denial notice. A late appeal may be accepted for good cause if you explain the reason in writing. The enrollee or a representative can file. For care not yet received, a treating doctor can also file on the enrollee's behalf after notifying the enrollee, and any doctor can ask for a fast appeal. Plans must accept a fast appeal by phone.
Level 2 is automatic. If the plan keeps its denial in whole or in part, it must send the case to the Independent Review Entity that contracts with CMS. The enrollee does not have to ask. For fast cases the plan must send it within 24 hours. CMS says that since May 1, 2026, this reviewer is C2C Innovative Solutions, Inc.
If the denial is reversed. If the plan fully reverses its denial on a fast appeal, it must approve or provide the care no later than 72 hours after it received the appeal request (or by the end of an allowed extension).
Situation B: the plan is ending a covered rehab stay
When the plan decides covered skilled nursing facility care should end, the nursing home must give a written Notice of Medicare Non-Coverage (NOMNC) no later than 2 days before covered services end. This applies even when a pre-approved block of days simply runs out. The notice is valid only once the enrollee or representative signs and dates it. If valid notice is not given, federal rules say the plan stays responsible for paying until 2 days after valid notice is received.
- Deadline. Federal rules say to contact the reviewer, by phone or in writing, by noon of the first day after the notice is delivered. Medicare and CMS guidance describe this as noon the day before the end date on the notice.
- Who reviews. CMS guidance says the review is done by the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) named on the notice.
- What happens next. The plan must send a Detailed Explanation of Non-Coverage (DENC) by close of business on the day the BFCC-QIO notifies the plan of the appeal. The plan has the burden of proving the end of coverage is correct, and the enrollee may submit evidence.
- Decision. The BFCC-QIO must decide by close of business the day after it has the information it needs.
If the noon deadline was missed. Since the 2025 coverage year, the BFCC-QIO still accepts a late request and decides as soon as possible. However, the next-day timeline and the protection from paying while waiting do not apply.
If the BFCC-QIO agrees with the plan. The enrollee may ask it to reconsider within 60 days, and that decision is due within 14 days. After that come the judge, Council and court levels. If coverage is found to end on a date, the enrollee is responsible for later costs unless that is reversed on appeal. If the stay may become long-term, see short-term rehab vs. long-term care.
Who can file a Medicare Advantage appeal for a parent?
A representative can file for the enrollee. CMS guidance says this can be someone named on Form CMS-1696 (Appointment of Representative) or an equivalent written notice, or someone authorized under state law, such as a court-appointed guardian or a person with a durable power of attorney or health care proxy. Any doctor can ask for a fast decision or fast appeal.
Where to look up nursing homes while the appeal goes on
You can search any certified nursing home by name, city or ZIP code on the nursing home search page, then compare nursing homes side by side. For what to ask the hospital before discharge, see how to choose a nursing home after a hospital stay.