Skilled nursing was denied because the patient is not improving. Is that appealable?
Yes. Medicare's skilled-care standard does not require improvement when skilled services are needed to maintain function or prevent deterioration, and many commercial plans use similar medical-necessity concepts. Appeal by showing the skilled nursing or therapy need, not just the hoped-for improvement.
What to do, in order
- Step 1
Separate improvement from skilled need
The issue is whether skilled care is required safely and effectively, not whether the patient is getting better every day.
- Step 2
Get the daily skilled services
List wound care, medication management, therapy complexity, fall risk, feeding, cognition, monitoring, and caregiver training.
- Step 3
Use the treating team's statement
Ask the physician and therapists to explain the risk of deterioration or unsafe discharge without skilled care.
- Step 4
For Medicare notices, use the QIO route immediately
If you received a NOMNC, the fast-track appeal deadline can be noon the day before coverage ends.
The deadline that applies
NOMNC fast-track appeals are due by noon of the day before services end (42 CFR 405.1200-405.1206; 42 CFR 422.626). Other plan denials generally follow the appeal date printed on the notice; employer and ACA plans provide at least 180 days.
Calculate your date →Documents to gather
- NOMNC or denial letter
- Daily nursing notes
- Therapy notes and safety assessments
- Physician statement on skilled need
- Discharge plan and caregiver limitations
Go deeper
Related questions
What is the Jimmo standard?
It is the Medicare clarification that skilled care can be covered to maintain function or prevent deterioration when skilled services are required.
Does this apply to Medicare Advantage?
MA plans must cover Medicare-covered benefits and use Medicare rules, while also considering the patient's individual circumstances.
What if the facility says the insurer decides everything?
The facility still has the records and must help provide them for a timely fast-track appeal.
Sources
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