Medicare skilled nursing denied: how to appeal

Quick answer

If Medicare (Original + Advantage) denied your skilled nursing facility, you can appeal, and the plan must give you its file and the criteria it used. Filing windows by plan type: 120 days from the notice (Original Medicare); 65 days from the notice (Medicare Advantage); 65 days from the notice (Part D). The date printed on your denial notice controls; it can only be later than these floors, never earlier.

Why Medicare (Original + Advantage) denies skilled nursing facility

Medicare is a federal program with two delivery modes, Original (fee-for-service Part A/B + Part D drug plans) and Advantage (private MA-C plans). Each has its own appeal ladder, and rights are stronger than most beneficiaries realize.

For skilled nursing facility specifically: Skilled nursing facility (SNF) coverage is denied at admission or, more often, ended mid-stay with a Notice of Medicare Non-Coverage. The clock on these denials is measured in hours, and the appeal runs through the Quality Improvement Organization, not the plan.

The law that controls this appeal

Medicare covers SNF care when the patient needs daily skilled nursing or skilled rehabilitation that can practically be provided only in a SNF (42 CFR 409.31 to 409.35). Coverage does not depend on the patient improving: skilled care to maintain function or prevent decline qualifies (Jimmo v. Sebelius settlement, 2013, and the Medicare Benefit Policy Manual, Chapter 8). Traditional Medicare requires a prior 3-day inpatient hospital stay; many Medicare Advantage plans waive it but must otherwise follow Medicare coverage rules (42 CFR 422.101(b)).

Note for Medicare (Original + Advantage): where the standard above cites ERISA or the ACA appeal rules, those describe employer and Marketplace plans. The windows and levels that apply to Medicare (Original + Advantage) are in the table below.

At a glance

Medicare (Original + Advantage) appeals: the rule, the deadline and the next level, by plan type

Original Medicare, Medicare Advantage and Part D each have their own federal ladder. The notice you received says which one you are in.

Plan type	Rule that governs	File your appeal within	The plan must answer	If the plan says no again
Original Medicare (Parts A and B) Fee-for-service Medicare. The Medicare Summary Notice lists the denial.	42 CFR Part 405, Subpart I.	Redetermination: 120 days from receipt of the initial determination (42 CFR 405.942). Reconsideration by a Qualified Independent Contractor: 180 days from the redetermination (§ 405.962). ALJ hearing: 60 days (§ 405.1002).	The Medicare Administrative Contractor decides a redetermination within 60 days (§ 405.950); the QIC decides within 60 days (§ 405.970).	QIC reconsideration, ALJ hearing (amount-in-controversy threshold), Medicare Appeals Council, federal district court. Fast-track appeals of service terminations go to the Quality Improvement Organization (42 CFR 405.1200 to 405.1206).
Medicare Advantage (Part C) A private plan that replaces Original Medicare. The card says Medicare Advantage, HMO, PPO or PFFS.	42 CFR Part 422, Subpart M (§§ 422.560 to 422.634). Coverage decisions must follow Original Medicare rules (42 CFR 422.101).	65 calendar days from the date on the denial notice to request the plan's reconsideration (42 CFR 422.582, as amended effective 1 January 2025).	Expedited: 72 hours. Standard pre-service: 30 days (7 days for Part B drugs). Payment: 60 days (42 CFR 422.590).	If the plan does not fully reverse itself it must send the case to the Independent Review Entity on its own (42 CFR 422.592); then an ALJ hearing when the amount in controversy meets the annual threshold, the Medicare Appeals Council and federal court. State external review does not apply.
Medicare Part D (drug plan or MA-PD) A stand-alone drug plan or the drug benefit inside a Medicare Advantage plan.	42 CFR Part 423, Subpart M; exceptions under 42 CFR 423.578.	65 calendar days from the date on the notice to request a redetermination (42 CFR 423.582, as amended effective 1 January 2025). Formulary, tiering and step-therapy exceptions need the prescriber's supporting statement (§ 423.578).	Redetermination: 7 calendar days standard, 72 hours expedited (42 CFR 423.590). Coverage determinations: 72 hours standard, 24 hours expedited, once the prescriber's statement is received (§§ 423.568, 423.572).	Independent Review Entity reconsideration on your request within 65 days of the redetermination notice (§ 423.600); then ALJ, Council and court.

Original Medicare (Parts A and B)

What you can demand. Follow the appeal instructions on the Medicare Summary Notice or use form CMS-20027. Your provider can appeal for you; any other representative needs form CMS-1696.

How to open the appeal. Cite 42 CFR 405.942 and the coverage rule that applies (the national or local coverage determination), and attach the treating clinician's statement addressed to each coverage criterion.

Medicare Advantage (Part C)

What you can demand. The plan may not apply internal criteria that are more restrictive than Medicare's national and local coverage determinations, and must decide medical necessity on your individual circumstances (42 CFR 422.101(b), (c)). You can ask for the case file and the criteria used.

How to open the appeal. Cite 42 CFR 422.582 and 422.101(c): the plan must decide on your individual circumstances under Medicare coverage rules, and must forward an unfavorable reconsideration to the IRE itself.

Medicare Part D (drug plan or MA-PD)

What you can demand. The exception turns on the prescriber's statement that the formulary alternative would be less effective or would harm you (42 CFR 423.578(b)(5)).

How to open the appeal. Cite 42 CFR 423.578 and 423.582 and attach the prescriber's supporting statement written to the exception standard.

Primary sources for this table

Windows are federal floors or the rule as written; the denial notice controls. Reviewed 13 September 2026. General information, not legal advice; Apellica is not a law firm.

What Medicare (Original + Advantage) denies for skilled nursing facility

The skilled nursing facility services most often denied:

SNF admission after a hospital stay for surgery, stroke, fracture, or infection
Continued coverage after the first one to two weeks of a stay
Stays where the plan says the patient has 'plateaued' or 'reached maximum benefit'
Admissions denied because the hospital stay was classed as observation rather than inpatient

Why skilled nursing facility claims get denied

A typical Medicare (Original + Advantage) skilled nursing facility denial almost always cites one of these reasons. Each one maps to a specific rebuttal in the appeal:

Plan says the patient no longer needs daily skilled care
Plan says care is 'custodial' or 'maintenance' only
No qualifying 3-day inpatient stay (traditional Medicare, or plans that keep the rule)
Medicare Advantage plan applied an internal algorithm or criteria beyond the Medicare rule
Documentation from the facility does not describe the skilled tasks being performed

The Medicare (Original + Advantage) appeal process

Appeal levels: 5 federal levels. Each has its own deadline; the ALJ and court levels require the amount in controversy to meet the annual threshold CMS publishes.

Carrier timing: 120 days from the notice for level 1 in Original Medicare (redetermination) or 65 days for Medicare Advantage reconsideration (42 CFR 422.582). Later levels: 180 days for the QIC reconsideration in Original Medicare, then 60 days each.

Skilled nursing timing for Medicare (Original + Advantage): the filing windows and decision clocks in the table above apply; the date on the notice controls.

What we know about Medicare (Original + Advantage): Medicare cases require a CMS-1696 Appointment of Representative form for us to act on your behalf. We provide this at intake.

Common Medicare (Original + Advantage) denial patterns for skilled nursing facility

Original Medicare: 5-level appeal. Redetermination by MAC → reconsideration by QIC → ALJ hearing → Medicare Appeals Council → federal district court. The QIC and ALJ levels reverse a substantial share of denials when properly briefed.
Medicare Advantage: identical 5-level ladder. MA plans must follow the same federal appeal structure as Original Medicare. Plan-level reconsideration → Independent Review Entity (Maximus) → ALJ → Council → federal court.
Part D drug coverage denials. Part D appeals follow a separate but parallel ladder. Tiering exceptions and formulary exceptions are filed before a coverage determination challenge.

How to win your Medicare (Original + Advantage) skilled nursing facility appeal

Strategy for skilled nursing facility: For a mid-stay cutoff, call the QIO before the deadline on the notice; coverage continues while the QIO decides. Ask the facility for the Detailed Explanation of Non-Coverage and the therapy and nursing notes. Show the specific skilled services being delivered (wound care, IV therapy, therapy that requires a licensed clinician) and, where the plan cites lack of progress, cite the maintenance-coverage standard. For Medicare Advantage denials, cite 42 CFR 422.101(b)(2): the plan may not use criteria more restrictive than Medicare's.

Filed against Medicare (Original + Advantage), that strategy rides on this procedural spine:

Procedural-rights anchor. Cite 42 CFR 405.942 and the coverage rule that applies (the national or local coverage determination), and attach the treating clinician's statement addressed to each coverage criterion. If your Medicare (Original + Advantage) coverage is a different plan type (Medicare Advantage, Medicare Part D), use that row of the table above instead; the rule and the deadline change with the plan, not the carrier.
Criteria-disclosure demand. Medicare (Original + Advantage) frequently denies on "not medically necessary" without disclosing the clinical criteria applied. Once disclosed, those criteria become the rebuttal map.
Controlling-standard citation. Medicare covers SNF care when the patient needs daily skilled nursing or skilled rehabilitation that can practically be provided only in a SNF (42 CFR 409.31 to 409.35). Coverage does not depend on the patient improving: skilled care to maintain function or prevent decline qualifies (Jimmo v. Sebelius settlement, 2013, and the Medicare Benefit Policy Manual, Chapter 8). Traditional Medicare requires a prior 3-day inpatient hospital stay; many Medicare Advantage plans waive it but must otherwise follow Medicare coverage rules (42 CFR 422.101(b)).
Treating-provider attestation. A letter from the treating physician addressing each criterion in Medicare (Original + Advantage)'s own policy language. This is the single strongest evidentiary element.
Requested action. A specific demand to reverse the skilled nursing facility denial and approve the service, not a general "please reconsider."

Documents you'll need for your Medicare (Original + Advantage) skilled nursing facility appeal

Notice of Medicare Non-Coverage (or the plan's denial) with the effective date
Detailed Explanation of Non-Coverage from the facility
Nursing notes and therapy notes for the disputed days
Hospital discharge summary and the inpatient admission order
Physician's certification of the need for skilled care

What a skilled nursing facility appeal can recover

Typical recovery for skilled nursing facility cases runs SNF care is billed per day; a denied stay of a few weeks is commonly a five-figure sum in billed charges. The amount at stake depends on the days denied and the plan's rates.. The exact figure depends on the specific service and your plan's contracted rates.

Medicare (Original + Advantage) skilled nursing facility appeals: frequently asked questions

The notice says coverage ends tomorrow. Is it too late to appeal Medicare (Original + Advantage)?

Not if you call the QIO listed on the notice by noon of the day before the effective date. Ask for a fast-track appeal. Coverage generally continues until the QIO decides.

Medicare (Original + Advantage) says my mother is not improving, so coverage stops. Is that right?

Improvement is not the standard. Medicare covers skilled care that maintains function or slows decline when the care itself requires a skilled professional. Ask the facility to document the skilled tasks and cite the maintenance-coverage standard from the Jimmo settlement.

What is the 3-day rule and does it apply to Medicare (Original + Advantage)?

Traditional Medicare requires a 3-day inpatient hospital stay before SNF coverage. Observation days do not count. Many Medicare Advantage plans waive the rule; check the Evidence of Coverage. If the hospital stay was classed as observation, that classification can itself be disputed.

Who decides the appeal, Medicare (Original + Advantage) or someone independent?

For a fast-track appeal, the Quality Improvement Organization, which is independent of the plan. For a standard Medicare Advantage appeal, the plan decides first and an adverse decision goes automatically to the Independent Review Entity.

What Apellica does for Medicare (Original + Advantage) skilled nursing facility appeals

We file appeals against Medicare (Original + Advantage) specifically configured to its internal review process. Every skilled nursing facility appeal embeds the criteria-disclosure demand, the procedural-rights anchor, the controlling-standard citation above, treating-provider attestation language, and the peer-reviewed evidence relevant to the denied service.

Cost: $0 upfront. We work on contingency for Medicare (Original + Advantage) appeals, if the appeal succeeds, we collect a percentage of the recovered claim value. If it fails, you owe nothing.

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Medicare (Original + Advantage) denied your skilled nursing facility? Here is what to do next