Inpatient rehabilitation denials
Inpatient rehabilitation facility (IRF) stays are denied at admission or cut short mid-stay, usually on the argument that a lower level of care such as a skilled nursing facility would do. The appeal turns on the medical record showing why intensive, physician-supervised rehabilitation is required.
The rule that controls this: 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.
Last reviewed 13 September 2026 · General information, not legal or medical advice · Apellica is not a law firm
What gets denied
- IRF admission after stroke, brain injury, spinal cord injury, hip fracture, or major joint replacement
- Continued-stay days once the plan decides goals can be met at a lower level of care
- Transfer from an acute hospital to IRF instead of a skilled nursing facility
- Rehab after cardiac surgery, transplant, or prolonged ICU stay (deconditioning)
Common denial reasons
- Plan says a skilled nursing facility or home health is 'the appropriate level of care'
- Therapy intensity (3 hours a day) is judged not tolerable or not required
- No documented need for daily physician supervision
- Pre-admission screening or physician certification missing from the record
- Medicare Advantage plan applied internal criteria beyond the IRF rule
How we approach the appeal
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.
Medicare Advantage: request reconsideration within 65 days of the notice; expedited decisions within 72 hours (42 CFR 422.582, 422.584). When an IRF stay is being ended, the facility issues a Notice of Medicare Non-Coverage and the patient can ask the QIO for fast-track review by noon of the day before coverage ends (42 CFR 422.626). Commercial and employer plans: at least 180 days to file an internal appeal; urgent pre-service decisions within 72 hours (29 CFR 2560.503-1; 45 CFR 147.136).
An IRF stay is billed per day at rates that make even a short denied stay a significant sum; the amount at stake depends on the length of stay and the plan's allowed amount.
- · 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)
Inpatient rehabilitation denial? Let's appeal it.
Two-minute micro intake. We confirm fit and reply within one business day with the right path for your situation.
Inpatient rehab denials by insurer
What each plan tends to cite, and the rule that controls it.
- UHC inpatient rehab denials
- Aetna inpatient rehab denials
- Cigna inpatient rehab denials
- BCBS inpatient rehab denials
- Humana inpatient rehab denials
- Medicare inpatient rehab denials
- Kaiser inpatient rehab denials
- Ambetter inpatient rehab denials
- Molina inpatient rehab denials
- BCBS FEP inpatient rehab denials
- WellCare inpatient rehab denials
This page provides general information about appeal strategy. It is not legal advice. Outcomes depend on documentation, plan terms, and timing.