Medicare Advantage denied inpatient rehabilitation? What the rule says and how to appeal.
Checked against the current rules on September 22, 2026.
A denial for inpatient rehabilitation isn't the end of the story — Medicare Advantage plans have to follow specific coverage rules, and a denial that doesn't square with those rules is exactly the kind of appeal that tends to win.
Here's what the rule actually requires, what evidence usually turns a denial around, and the deadline you're working against.
What the rule requires
Coverage for inpatient rehabilitation under a Medicare Advantage plan is governed by§ 412.622 Basis of payment. andInpatient Rehabilitation Facility (IRF) Services. A Medicare Advantage plan generally cannot apply a stricter test than what these rules require.
Questions that decide it
Before you appeal, these are the facts that usually decide whether a denial like this holds up:
Is the patient currently able to take part in several hours of therapy a day?
Did a doctor see the patient in person regularly during the stay (multiple times a week)?
Was the patient transferred to the rehab facility directly from a hospital stay for the same condition?
What a winning appeal has to show
An appeal that wins usually includes:
The IRF's own therapy plan showing multiple disciplines (PT, OT, speech, or prosthetics/orthotics) — §412.622(a)(3)(i) requires active, ongoing therapy from multiple disciplines, one of which must be PT or OT. (The facility provides this.)42 CFR 412.622
A log of in-person physician visits during the stay — IRF coverage requires regular physician involvement in the interdisciplinary team approach. (The facility provides this.)Inpatient Rehabilitation Facility (IRF) Services
Hospital transfer/discharge records showing the direct transfer and the condition being treated — Ties the IRF admission to a completed, related course of hospital treatment, not a substitute for it. (The facility provides this.)Inpatient Rehabilitation Facility (IRF) Services
Therapy notes documenting active participation in the intensive program — §412.622(a)(3)(ii) requires the patient reasonably be expected to actively participate in and benefit from intensive rehabilitation therapy. (The facility provides this.)42 CFR 412.622
Your deadline to appeal
65 days from the date on the notice. The rule (42 CFR § 422.582) gives you 60 days from when you receive the denial, and receipt is presumed to be 5 days after the notice's own date unless shown otherwise — 60 + 5 = 65 days from the notice date.42 CFR 422.582
The plan itself then has its own clock to decide. The plan must decide within 30 calendar days for a request about a service you haven't received yet, 60 calendar days for a request about payment for something already provided, or 72 hours if the request is expedited (42 CFR § 422.590).
What to ask your doctor to address
If you're asking the treating physician for a supporting letter, it should speak to:
The diagnosis and functional status requiring intensive inpatient rehabilitation.42 CFR 412.622
Which therapy disciplines were medically necessary and why more than one was required.42 CFR 412.622
The patient's ability, at the time of admission, to actively participate in several hours of therapy a day.42 CFR 412.622
The date and reason for transfer from the referring hospital.Inpatient Rehabilitation Facility (IRF) Services
Questions people ask
- Can the plan just say it's "not medically necessary" with no further explanation?
- The denial notice has to explain the basis for the decision and tell you how to appeal. If it doesn't point to a specific rule or criteria, that's itself worth raising in your appeal — you're entitled to know what standard was applied.
- What if I don't have all the evidence listed above?
- Include what you have. An appeal with partial evidence and a clear explanation of the rule still gets a real review — it doesn't need to be complete to be worth filing.
Sources — last checked September 22, 2026
- § 412.622 Basis of payment.as of September 18, 2026
- 42 CFR 422.582as of September 18, 2026
- Inpatient Rehabilitation Facility (IRF) Servicesas of September 22, 2026
Related
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By CaseWhy Appeals editorial. See how this content is produced. Not legal advice. Not affiliated with or endorsed by Medicare, CMS, or any health plan. A product of CaseWhy LLC.
