Inpatient rehabilitation appeal letter template
A free, fillable inpatient rehabilitation appeal letter you can copy, complete, and send. It is built on the structure that actually wins inpatient rehabilitation appeals, not a generic reconsideration request.
The inpatient rehabilitation appeal letter template
Copy the template below and replace every bracketed field with your details. Keep it to one or two pages plus attachments.
[Date] [Your full name] [Your address] [Your phone] · [Your email] [Insurer name], Appeals Department [Appeals address from your denial letter] Re: Appeal of inpatient rehabilitation denial Member: [Patient name] · Member ID: [Member ID] · Group: [Group #] Claim #: [Claim #] · Date(s) of service: [Date of service] Denial date: [Denial date] · Denial/reason code: [Code] To the Appeals Department: I am formally appealing [Insurer]'s [denial date] denial of [service or medication]. I request that the denial be overturned and the inpatient rehabilitation approved. 1. The denial. [Insurer] denied this inpatient rehabilitation stating, verbatim: "[paste the exact denial language from your letter]." 2. Why the denial is incorrect. [State, in one or two sentences, why the service is medically necessary for your condition, and answer the specific reason the plan gave.] 3. The controlling standard. [See the standard for this denial type below, then cite it here.] 4. The evidence. I am attaching: - A letter of medical necessity from my treating provider addressing each clinical criterion; - [Your supporting records: see the document checklist below]; - The clinical guidelines and records that support coverage. 5. My request. I request a full reversal of this denial and approval of [service or medication] within the timeframe required by law. If the denial is upheld, please provide in writing the specific clinical criteria used, the credentials of the reviewing clinician, and instructions for independent external review. Under 29 C.F.R. 2560.503-1 (employer plans) or 45 C.F.R. 147.136 (ACA plans), please also provide all documents and records relevant to this claim. Sincerely, [Patient name / authorized representative]
The controlling standard for inpatient rehabilitation denials
For Medicare and Medicare Advantage, the IRF coverage criteria at 42 CFR 412.622(a)(3): a need for active and ongoing therapy in at least two disciplines (one being PT or OT), an intensive program (generally 3 hours a day at least 5 days a week), close physician supervision, and a reasonable expectation of measurable improvement. Medicare Advantage plans may not apply stricter internal criteria than traditional Medicare (42 CFR 422.101(b)). Commercial plans apply their own level-of-care criteria (often MCG or InterQual), which must be disclosed on request under 29 CFR 2560.503-1 and 45 CFR 147.136.
What makes a inpatient rehabilitation appeal letter win
Get the rehabilitation physician's admission note, the pre-admission screening, and the therapy evaluations. Map each element of the IRF criteria to a page in the record: multiple disciplines, intensity, medical supervision, expected improvement. For Medicare Advantage, cite 42 CFR 422.101(b)(2), which binds the plan to traditional Medicare coverage rules. If the patient is already admitted and the plan is ending coverage, use the fast-track review (see Timing) before the effective date so services continue during review.
The letters that get overturned share a structure: they quote the denial, rebut the plan's specific criteria point by point, cite the controlling standard above, attach a treating-provider letter of medical necessity, and make a clear demand for reversal. Generic letters that simply ask the plan to reconsider do not move reviewers.
Documents to attach
- The denial or non-coverage notice with its effective date
- Rehabilitation physician admission note and pre-admission screening
- PT, OT and speech therapy evaluations and daily notes
- Acute hospital discharge summary
- Any plan-issued clinical criteria (request them in writing)
Skip the blank page
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Build my appeal free →Inpatient rehabilitation appeal: frequently asked questions
Can my insurer send me to a nursing home instead of inpatient rehab?
The plan can propose it, and you can appeal it. The question the reviewer must answer is whether the record shows a need for intensive, multidisciplinary, physician-supervised rehabilitation. If it does, a skilled nursing facility is not an equivalent level of care.
How fast does a my insurer inpatient rehab appeal move?
Pre-admission and continued-stay disputes qualify as urgent because delay can jeopardize recovery. Urgent decisions are due within 72 hours. For Medicare Advantage, a fast-track QIO review requested before the effective date keeps coverage in place during the review.
Does the three-hour rule mean I have to do three hours of therapy every day?
The Medicare IRF criteria describe an intensive program that generally means 3 hours a day at least 5 days a week, but the rule allows the intensity to be measured over a 7-day period in individual cases and does not require it from day one for every patient. The physician's documentation of why the patient needs and can participate in the program is what matters.
What if my insurer already cut off my stay?
Appeal anyway. A retrospective appeal can recover days the plan refused to cover, and the medical record from those days is the evidence.