UnitedHealthcare Medicare Advantage Denials: Complete Appeal Guide
UnitedHealthcare is the largest Medicare Advantage insurer in the U.S., covering over 8 million seniors. They're also one of the most aggressive deniers, particularly for post-acute care like skilled nursing and rehab.
If you've been denied by UHC Medicare Advantage, this guide will show you exactly how to appeal—and win.
The Medicare Advantage Denial Crisis
What this means: UHC Medicare Advantage denies far more post-acute care than traditional Medicare would. But the good news? Most of these denials are overturned when you appeal.
The NaviHealth Problem
UnitedHealthcare uses NaviHealth—an AI-powered system they own—to automatically deny Medicare Advantage claims for:
- Skilled nursing facility (SNF) stays
- Inpatient rehabilitation
- Home health care
- Long-term acute care (LTAC)
How NaviHealth Denies Your Care
The Algorithm: NaviHealth predicts how long recovery "should" take based on your diagnosis code and basic demographics—not your individual circumstances.
What it ignores:
- Your specific complications or comorbidities
- Your home environment (stairs, caregiver availability, safety)
- Your baseline function before illness
- Your doctor's clinical judgment
- Your actual progress in therapy
The result: NaviHealth automatically cuts off care once its algorithm says you've had "enough"—regardless of whether you've actually recovered.
NaviHealth Lawsuits
Multiple class-action lawsuits have been filed:
- Wegner v. UnitedHealth (2023): Alleges UHC uses AI to override physician judgment in Medicare Advantage
- Eichhorn v. UnitedHealth (2023): Claims 90% of NaviHealth denials are reversed when patients appeal
- CMS Investigation (2024): Federal audit of NaviHealth's Medicare Advantage denial practices
If NaviHealth denied your care, you have strong grounds to appeal.
Medicare Advantage Appeal Rights
Medicare Advantage appeals are governed by federal CMS regulations, not state law. You have specific timelines and rights:
Appeal Levels
- Reconsideration (UHC): Internal appeal to UnitedHealthcare
- IRE Review: Independent Review Entity (third party)
- ALJ Hearing: Administrative Law Judge (for claims ≥$180)
- Medicare Appeals Council: Federal review
- Federal Court: Judicial review (for claims ≥$1,850)
Important Timelines
| Denial Type | Your Deadline to Appeal | UHC's Decision Deadline |
|---|---|---|
| Standard Pre-Service | 60 days | 30 days |
| Expedited Pre-Service | 60 days | 72 hours |
| Standard Post-Service | 60 days | 60 days |
| Payment Denial | 60 days | 60 days |
How to Appeal NaviHealth Denials
Step 1: Request Immediate Physician Review
When NaviHealth denies care, demand a physician review instead of accepting the AI decision:
To: UnitedHealthcare Medicare Advantage Appeals
Re: [Name, Medicare ID, Claim #]
I appeal the denial of [skilled nursing/rehab/home health] dated [date].
I specifically request that this appeal be reviewed by a physician licensed in my state, not by the NaviHealth algorithm. Federal regulations require medical necessity determinations be made by qualified health care professionals, not automated systems.
The NaviHealth system does not account for my individual circumstances, including [list your specific factors: complications, home environment, baseline function, etc.].
Attached is a letter from my treating physician explaining why I require continued [care type].
Step 2: Get Strong Physician Documentation
Your doctor's letter should:
- Explain your individual need: Why YOU specifically need more care (not just diagnosis)
- Document your progress: Therapy notes showing you're improving but not yet safe
- Address home environment: Why home care is unsafe (stairs, no caregiver, fall risk, etc.)
- Cite Medicare coverage criteria: Show you meet the "skilled care" requirements
- Reference NaviHealth problems: Note that algorithm doesn't account for individual factors
- Provide clinical justification: Medical reasons for continued care
Step 3: Challenge the Algorithm
In your appeal, specifically address NaviHealth's limitations:
Language to Use
"The NaviHealth algorithm that denied my care is currently under investigation by CMS and is the subject of multiple class-action lawsuits alleging systematic over-denials. Studies show up to 90% of NaviHealth denials are reversed on appeal.
This algorithm cannot replace individualized clinical judgment. My treating physician, who has examined me and knows my medical history, has determined that I require continued [care type]. An algorithm that has never seen me cannot overrule this clinical determination.
I request that a physician—not an algorithm—review my case and consider my individual circumstances."
Step 4: Submit Therapy Documentation
Include evidence of your need for skilled care:
- Therapy notes: PT/OT/ST progress notes showing ongoing skilled need
- Functional assessments: Documentation of ADL limitations
- Safety concerns: Fall risk assessments, cognitive status
- Goals not met: Show you haven't achieved independence yet
- Skilled services needed: What skilled nursing or therapy services you require
Step 5: Use Expedited Appeal When Appropriate
Request expedited (fast-track) appeal if:
- You're currently receiving the care that's being terminated
- Delay would seriously jeopardize your health or ability to regain function
- You're being discharged and believe you still need skilled care
Expedited timeline: UHC must decide within 72 hours.
How to request: Call UHC and say "I request an expedited appeal because [state health risk]." Follow up in writing.
Level 2: Independent Review Entity (IRE)
If UHC denies your internal appeal, your case automatically goes to an Independent Review Entity:
IRE Review Facts
- Automatic: For service denials, UHC must forward to IRE within 24 hours
- Independent: IRE is not paid by UHC, no conflict of interest
- Binding: If IRE approves, UHC must provide coverage
- Timeline: 30 days for standard, 72 hours for expedited
- Free: No cost to you
What Happens at IRE
- UHC forwards your case file to IRE (you can submit additional evidence too)
- IRE physician reviewer examines all evidence
- IRE determines if care is medically necessary under Medicare coverage rules
- IRE issues binding decision
IRE success rate for NaviHealth denials: Very high. IRE reviewers frequently overturn UHC's AI-driven denials.
Submitting Additional Evidence to IRE
You can submit new evidence directly to the IRE:
- Updated physician letters
- Recent therapy notes
- Functional assessments
- Documentation of complications or setbacks
- Evidence of unsafe discharge
How to submit: Contact the IRE directly (UHC's denial letter will include IRE contact info) or submit through UHC.
Continuation of Benefits
If you're currently receiving care that UHC wants to terminate, you have the right to continue receiving that care during your appeal:
How to Get Continuation of Benefits
Deadline: Request within the later of:
- 60 days of denial notice, OR
- Before the termination date stated in the notice
How to request: "I request continuation of benefits during my appeal pursuant to 42 CFR §422.619."
Important: If you lose the appeal, you may have to pay for the continued services. However, if you win, UHC must cover everything.
Common Medicare Advantage Denial Types
Skilled Nursing Facility (SNF) Denials
UHC's tactics:
- Claiming you don't meet "skilled care" requirements
- NaviHealth says you've had "enough" days based on diagnosis
- Alleging care is "custodial" not "skilled"
- Claiming you can do therapy at home
How to fight:
- Show ongoing skilled nursing or therapy needs
- Document why home environment is unsafe
- Prove you're making progress but not yet independent
- Cite Medicare SNF coverage criteria (3-day hospital stay, skilled need, reasonable and necessary)
Inpatient Rehab Denials
UHC's tactics:
- Claiming you don't need intensive rehab (3 hours/day)
- Alleging SNF-level rehab would be sufficient
- NaviHealth says diagnosis doesn't warrant inpatient rehab
How to fight:
- Document need for intensive, multidisciplinary rehab
- Show you meet 60% rule (at least 60% of patients have 1 of 13 conditions)
- Prove you can tolerate and benefit from 3 hours therapy/day
- Demonstrate physician supervision requirement
Home Health Denials
UHC's tactics:
- Claiming you're not homebound
- Alleging services aren't "skilled"
- Cutting off visits before you've reached independence
How to fight:
- Document homebound status (can't leave home without considerable effort)
- Show skilled nursing or therapy need (not just personal care)
- Prove services are intermittent and reasonable
- Demonstrate ongoing progress toward goals
When to Contact CMS
In addition to appealing, file a complaint with CMS (Centers for Medicare & Medicaid Services) if:
- NaviHealth is overriding physician judgment
- UHC is systematically denying post-acute care
- UHC missed appeal deadlines
- You believe UHC is violating Medicare coverage rules
How to File CMS Complaint
- Phone: 1-800-MEDICARE (1-800-633-4227)
- Online: Medicare.gov complaint form
- Mail: Medicare Beneficiary Ombudsman
Why this matters: CMS regulates Medicare Advantage plans. Multiple complaints about UHC can trigger investigations, audits, or enforcement action.
Resources
- 1-800-MEDICARE: Free help with Medicare appeals (1-800-633-4227)
- CMS Medicare Appeals: cms.gov/medicare/appeals-and-grievances
- State Health Insurance Assistance Program (SHIP): Free local counseling - find at shiphelp.org
- Medicare Rights Center: medicarerights.org (helpline: 1-800-333-4114)
- Center for Medicare Advocacy: medicareadvocacy.org