You are on Valero's UnitedHealthcare Group Medicare Advantage PPO in Texas, and the denials have reached the point where they are shaping what care you can actually get — the drugs your doctors prescribe, the physical therapy you need, the rehab after the crash. This walks through what to do about the denials happening now, what the realistic alternatives are, and which of those alternatives are actually available to you.
Your plan is financially generous and functionally restrictive, and those are different things. On paper it is a strong plan — a $0 out-of-pocket maximum on covered services, a national network, a Valero premium contribution. But a $0 out-of-pocket maximum caps what you pay for care the plan approves. It does nothing for care the plan refuses. A denied service isn't a copay. It's the whole bill, or more often, it's care you simply don't receive.
So the question isn't "is this a good plan." It's: which option actually gets you the specific care you need? Three findings from the research shaped the answer.
Across Medicare Advantage, roughly 67–81% of appealed denials are overturned. For skilled nursing denials it is 95%. Yet only about 12% of denials are ever appealed. And several of your specific denials look like they may be legally wrong, not merely clinically debatable — see Your conditions.
Original Medicare has no prior authorization for outpatient physical therapy. None — not in any state, at any dollar amount, ever. There is also no visit limit. Your plan covers 6 visits, then requires clinical review, then re-authorizes in increments. Given that PT matters for the trigeminal neuralgia, the post-crash recovery, and the osteoporosis, this is the single largest gap between what you have and what you need. More →
Based on the actual questions Texas Medigap carriers ask, neither of you would likely be approved for an individual Medigap policy today. Not because of anything you did — because of how the questions are written. One carrier asks whether you have received physical, occupational, or speech therapy in the last 12 months. Another asks whether you have been "advised by a physician to have treatment, follow-up visits, further diagnostic evaluation, testing or therapy" with no time limit at all — which ongoing cancer surveillance answers "yes" to indefinitely.
That matters enormously before anyone spends months planning around it. The detail →
Your experience is not unusual, and it is not the result of doing something wrong.
| Finding | Figure | Source |
|---|---|---|
| Prior authorization determinations in Medicare Advantage, 2024 | 52.8 million | KFF |
| Prior authorization reviews in all of traditional Medicare, same period | ~625,000 | CMS |
| UnitedHealth Group denial rate — highest among major insurers examined | 12.8% | KFF |
| Long-term care hospital admission denials | 65% | HHS OIG |
| Inpatient rehabilitation facility denials | 54% | HHS OIG |
| Denials that are ever appealed | ~12% | KFF |
| Appeals that are overturned in the patient's favor | 67–81% | KFF |
| Appealed skilled nursing denials that are overturned | 95% | HHS OIG, June 2026 |
A $0 out-of-pocket maximum protects you against cost. It does not protect you against a denial. If a plan refuses to authorize rehab after a hospital stay, you pay 100% of it — or more often, you simply don't get it. The protection is on the wrong axis from the problem.
The problem is not that the plan is too expensive. It is that you are not able to get the care your doctors have prescribed. That framing matters, because otherwise every conversation gets answered with a premium comparison — and a premium comparison is not the problem you have.