Skilled nursing facility appeal letter template
A free, fillable skilled nursing facility appeal letter you can copy, complete, and send. It is built on the structure that actually wins skilled nursing facility appeals, not a generic reconsideration request.
The skilled nursing facility 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 skilled nursing facility 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 skilled nursing facility approved. 1. The denial. [Insurer] denied this skilled nursing facility 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 skilled nursing facility denials
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)).
What makes a skilled nursing facility appeal letter win
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.
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
- 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
Skip the blank page
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Build my appeal free →Skilled nursing facility appeal: frequently asked questions
The notice says coverage ends tomorrow. Is it too late to appeal my insurer?
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.
my insurer 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 my insurer?
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, my insurer 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.