In April of this year, a Medicare Advantage enrollee contacted CMA with questions about her stay in a Skilled Nursing Facility (SNF). She had broken her leg and required short-term rehabilitation before she could safely return home. Her orthopedist and therapists agreed it would be weeks before she could return to the apartment she shared with her husband, who himself required care due to his dementia. Despite the medical recommendations, the enrollee received a denial of coverage from her Medicare Advantage Plan just days into her SNF stay. This denial directly conflicted with the advice of her treating physicians and Medicare coverage criteria because she was receiving daily physical therapy and required a Hoyer lift for transfers. The enrollee appealed the denial, and it was overturned. To date, the beneficiary has now received five initial denials, even though her condition actually worsened when she developed Stage 3 pressure wounds on her heels.
She has appealed each denial, sometimes twice, and has been successful every time. She estimates she spends at least 20 hours per week calling her Advantage Plan, managing appeals and deadlines, making sure her medical records are up-to-date and accurately transferred to her Advantage Plan, and coordinating with her medical team. The undue stress these denials have caused have slowed her recovery. Instead of focusing on her health, rest, and strength, she has been fighting denials, worrying about how she will pay for care out-of-pocket if ultimately denied, or how to return to her home which -without a Hoyer lift and trained professionals in the home- would be against medical advice.
Last week, the Center for Medicare Advocacy assisted the client with filing a grievance with her Medicare Advantage Plan after she received her fifth denial. Routine, repeated denials are prohibited under CMS guidelines Medicare Claims Processing Manual Chapter 30 Section 40.2.2. Unfortunately, these excessive and usually erroneous denials continue to be standard practice by most Medicare Advantage Plans.
If you or someone you know is experiencing these types of denials, CMA has a toolkit available here. Enrollees have 60 days after the event or incident to file a grievance. It is important to remember that a grievance is a separate form of complaint against the Plan; a grievance does not take the place of an appeal. Filing a grievance is a way to force accountability and push back against this harassing denial practice.
June 5, 2025 – C. Huberty