Post-acute denials are criteria-heavy. The appeal should be criteria-mapped.
Medicare Advantage post-acute denials — prior-authorization rejections, continued-stay terminations, and retrospective admission denials — represent one of the most disputed categories in the system. Federal oversight data documents high appeal-overturn patterns. The cases are winnable. The argument has to be clinical.
OIG reports confirm what you already know: these denials are frequently overturned.
The HHS Office of Inspector General has published multiple reports documenting that Medicare Advantage organizations deny post-acute services at rates that are overturned on appeal at high frequencies — indicating that the original denials often do not withstand clinical scrutiny.
The implication for post-acute providers: appealing is not optional. The question is whether the appeal contains the criteria-mapped physician reasoning that moves the case from "clinical narrative" to "criteria-specific rebuttal."
Read: Post-Acute Denials — What Federal Oversight Data Shows →
Skilled Nursing Facility Denials
Admission denials, continued-stay terminations, and retrospective MA denials for skilled nursing. The denial typically conflates acute stability with absence of skilled-care need — these are separate clinical questions.
Inpatient Rehabilitation Facility Denials
Medical-necessity denials challenging rehabilitation potential, intensity of service requirements, or appropriateness of the IRF setting vs. SNF or home health.
Long-Term Acute Care Denials
Admission and extended-stay denials for patients requiring prolonged acute care — ventilator weaning, complex wound management, IV antibiotic courses exceeding acute-care length-of-stay expectations.
Home Health Prior-Authorization Denials
Prior-auth denials for home health services — homebound status challenges, skilled-need disputes, and visit-frequency reductions.
One overturned SNF denial can cover months of desk cost.
$1,000 fixed fee
Three standard post-acute denials reviewed with full physician deliverables.
Per-diem × denied days
The exposure on a denied SNF stay is your contracted per-diem multiplied by the denied days. Assess it from the actual remittance and contract amounts — a multi-week denied stay is routinely material enough to justify a fixed-fee physician review.
$15,000 – $60,000+
IRF and LTACH denials involve higher per-diem rates and longer stays. A single overturned case can be transformative.
Clinovian's clinical methodology is grounded in payer-side utilization-management review — applying criteria, making determinations, and understanding how post-acute denial decisions are constructed. That experience means the desk's output maps to the reviewer's decision framework, not generic clinical narrative.
Post-acute denials are the desk's strongest natural territory. The criteria frameworks, the denial rationale patterns, and the documentation gaps are patterns we've seen from the review side — and now apply from the appeal side.
Send one de-identified post-acute denial rationale. Initial fit response in 24–48 hours.
No PHI and no commitment. The initial screen confirms scope and the records required. Suitable matters may proceed to a paid evaluation or individual physician review.