Inpatient rehab was denied after a hospital stay. How do I appeal?
An inpatient rehab denial usually says the plan believes skilled rehab is not medically necessary, a lower level of care is enough, or the patient does not need multiple therapy disciplines. Appeal with the hospital discharge plan, therapy evaluations, physician order, and records showing why home health or outpatient therapy is not safe or adequate.
What to do, in order
- Step 1
Get the rehab criteria
Ask for the inpatient rehab policy, including admission criteria, therapy intensity, physician supervision, and discharge alternatives the plan considered.
- Step 2
Document why a lower level is unsafe
Use therapy notes, nursing needs, fall risk, wound care, cognitive status, medication complexity, and caregiver limitations.
- Step 3
Get the rehab physician or hospitalist statement
The statement should explain why inpatient rehab is needed now and why SNF, home health, or outpatient therapy will not meet the patient's needs.
- Step 4
Request expedited review when discharge is imminent
If the patient is still hospitalized or placement is pending, ask for urgent handling so the decision comes before unsafe discharge.
The deadline that applies
For employer and ACA plans, at least 180 days to appeal, with urgent pre-service appeals decided within 72 hours and standard pre-service appeals within 30 days (29 CFR 2560.503-1; 45 CFR 147.136). Medicare Advantage appeals use the 60-day reconsideration window in 42 CFR 422.582, with expedited review when delay risks health.
Calculate your date →Documents to gather
- Hospital discharge summary
- PT/OT/speech evaluations
- Physician order for inpatient rehab
- Home safety and caregiver limitations
- The plan's inpatient rehab policy
Go deeper
Related questions
Is inpatient rehab the same as a skilled nursing facility?
No. Inpatient rehab is a hospital-level rehabilitation program with intensive therapy and physician supervision; SNF is a lower level of skilled care.
Can family preference win this appeal?
No. The record has to show clinical need and why the lower level is unsafe or inadequate.
Should the hospital help?
Yes. Ask the case manager and rehab physician for the criteria, records, and expedited appeal support before discharge.
Sources
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