Medicare Plans Compared Based on Denial Rates for Specialized Care

Private Medicare plans are denying requests for specialized medical care at widely varying rates.

In some cases, denial rates were strikingly high, especially for some of the largest Medicare Advantage companies: CVS Health/Aetna, Humana and UnitedHealth Group, according to a new inspector general report.

Some of these insurers, while being some of the most prominent in the U.S., routinely reject requests for post-hospital care such as rehabilitation and long-term treatment.

Why It Matters

More than half of Medicare beneficiaries are now enrolled in Medicare Advantage plans, which are run by private insurers rather than the federal government. The plans often mandate prior authorization before patients can receive certain treatments, and that process can delay or even block medically necessary care.

The new report suggests, however, that approval rates can differ dramatically depending on the insurer, the type of care requested and whether patients appeal a denial.

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What To Know: Medicare Plans Compared by Denial Rates

The Department of Health and Human Services' (HHS) Office of Inspector General uncovered stark differences among insurers, particularly for specialized post-acute care.

Long-Term Care Hospitals (LTCH)

CVS Health (Aetna): Denied about 80 percent of requests

Humana: Denied about 72 percent

UnitedHealthcare: Denied about 71 percent

Other insurers (average): About 42 percent denial rate

Inpatient Rehabilitation (IRF)

UnitedHealthcare: Denied about 66 percent of requests

Humana: Denied about 54 percent

CVS Health (Aetna): Denied about 51 percent

Other insurers (average): Roughly 41 percent

Skilled Nursing Facility Care

Overall denial rate across plans: about 12 percent

However, 95 percent of denials were overturned on appeal, suggesting many requests may have been wrongly rejected initially

These services are typically required by patients recovering from serious medical events such as strokes, heart conditions or major injuries.

Coverage Denials Are Often Reversed

The new report also revealed a common trend in how frequently insurers reverse their decisions after a patient appeals.

About 36 percent of long-term care denials and 43 percent of rehab denials were overturned. And for some services like nursing home care, overturn rates were even higher, approaching 95 percent.

That means some patients may be initially denied care that meets Medicare coverage rules, Kevin Thompson, CEO of 9i Capital Group and host of the 9innings podcast, said.

“It reveals what many of us have always known about capitalism mixed with healthcare. You show me the incentive and I will show you the outcome,” Thompson told Newsweek . “Now with the advent of AI, private insurers will deny first and then receive an appeal to deny a second time, just to see if it’s appealed once again before they approve.”

What Type of Care Is Most Affected

The denials are concentrated in post-hospital specialized care, including:

Long-term acute care hospitals

Inpatient rehabilitation facilities

Skilled nursing facility admissions

These services are often needed after a hospital stay, when patients require additional recovery time, therapy or monitoring before returning home.

“Beneficiaries often get lost in the process, and what could be a life-saving treatment or transfer to an acute care facility can be delayed for days or even weeks,” Thompson said.

“When my father was in a facility, I was told this was simply the reality of the system. Staff explained that requests often have to be submitted three or four times, with the expectation that the first denial is almost automatic.”

Why Denial Rates Vary

The coverage denial variation likely comes down to differences in insurer policies and use of prior authorization as well as the specific policies of third-party contractors reviewing claims.

There are also likely financial incentives involved, with for-profit insurers showing higher denial rates, experts say.

“For beneficiaries, the lesson from the data is to appeal quickly, involve their doctor and family when possible, and never assume an initial denial is final,” Alex Beene, financial literacy instructor at the University of Tennessee at Martin, told Newsweek .

What This Means for You

If you or a family member is on a Medicare Advantage plan:

Check plan rules carefully for post-hospital care

Be prepared for prior authorization requirements

Consider appealing any denial, as reversal rates can be high

Compare plans not just on premiums—but on coverage rules and approval patterns

What Are Insurers Saying?

Insurance groups have pushed back on the findings, saying that prior authorization is a necessary tool to control healthcare costs and ensure treatments meet medical criteria.

"Our priority is helping patients get the care they need without unnecessary delays," Aetna said in a statement to Yahoo News. "We review requests promptly, offer a clear appeals process, and are leading the way for continuous patient-centered improvements."

AHIP,…