Skilled nursing facility denials
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.
What gets 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
Common denial reasons
- 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
How we approach the appeal
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.
Notice of Medicare Non-Coverage: contact the QIO no later than noon of the day before the effective date on the notice for fast-track review (42 CFR 405.1200 to 405.1204 for traditional Medicare; 42 CFR 422.626 for Medicare Advantage). If that window is missed, a standard appeal remains available (65 days for Medicare Advantage reconsideration, 42 CFR 422.582). Commercial plans: at least 180 days to file an internal appeal.
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.
- · 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
Skilled nursing facility 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.
Start Your AppealThis page provides general information about appeal strategy. It is not legal advice. Outcomes depend on documentation, plan terms, and timing.