Questions & answers · Health insurance
My Medicare Advantage plan denied a skilled nursing facility stay that traditional Medicare would have covered. Is that allowed?
Health insuranceDeniedChecked Nov 6, 2026
From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-06 · Source: GovInfo · 42 CFR 422.101 Requirements relating to basic benefits · § 422.101(c)(1)(i)(A)–(B) View original ↗
In short
- A plan has to use the Medicare coverage rules for basic benefits.
- It can't deny on criteria those rules don't set.
- Appeal in 60 days, or ask for a fast appeal.
What this means
The federal rule says a Medicare Advantage plan has to use the Medicare coverage rules. It can't deny basic benefits on criteria that those rules do not set [1]. It must also ask if the care is reasonable and necessary under Medicare law [1].
For a skilled nursing stay, Original Medicare asks for a 3-day hospital stay first. Medicare.gov says Advantage plans may waive that. Ask your plan [2]. To appeal, ask within 60 days of the written denial [3]. If your nursing services are ending too soon, you may ask for a fast appeal [4].
Your next step
Appeal within 60 calendar days after you receive the written denial notice [3]. If your nursing services are ending too soon, you may ask for a fast appeal [4].
Check it yourself
Your denial notice and your Notice of Medicare Non-Coverage show the steps. The sources do not give the Original Medicare SNF coverage criteria in detail — "Don't know yet".
Where this comes from (4)
[1] GovInfo · 42 CFR 422.101 Requirements relating to basic benefits · § 422.101(c)(1)(i)(A)–(B) · checked 2026-11-06
Coverage and benefit criteria as specified at paragraphs (b) and (c) of this section and may not deny coverage for basic benefits based on coverage criteria not specified in paragraph (b) or (c) of this section … Whether the provision of items or services is reasonable and necessary under section 1862(a)(1) of the Act
[2] Medicare.gov · Skilled nursing facility (SNF) care · checked 2026-11-06
Medicare Advantage Plans may also waive the 3-day minimum inpatient hospital stay. Contact your plan for more information
[3] GovInfo · 42 CFR 422.582 Request for a standard reconsideration · § 422.582(b) · checked 2026-11-06
a request for reconsideration must be filed within 60 calendar days after receipt of the written organization determination notice
[4] Medicare.gov · Fast appeals · page text · checked 2026-11-06
You may have the right to ask for a fast appeal if you think your services are ending too soon (or that you're being discharged too soon) from one of these providers: Hospital Skilled nursing facility (SNF)
How we found this
We matched your question to 4 official sources, quoted the exact lines, and re-checked each quote against its source on 2026-11-06.
What we don’t know yet
Your own plan or notice may say something different. If your letter cites another rule, send it and we will look again.
Every answer is checked against the official rule it quotes.
Information only — not legal advice. Your plan, insurer or agency decides.
This answer quotes the official sources listed above, with the date we checked them. Your own policy, notice and state rules control. We are not your lawyer or your insurer. We don’t file, argue or negotiate claims for you — you send any letter or form yourself.
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