Medicare Advantage denied skilled nursing facility care? What the rule says and how to appeal.
Checked against the current rules on September 22, 2026.
A denial for skilled nursing facility care 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 skilled nursing facility care under a Medicare Advantage plan is governed bySkilled Nursing Facility Level of Care - General andSkilled Services Defined. 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:
Was there a hospital stay right before this nursing home stay, for a related medical condition?
Does the nursing home's own records show skilled nursing or therapy happening every day, not just a few times a week?
Did the denial say the patient "plateaued," "isn't improving," or has "reached maximum benefit"?
What a winning appeal has to show
An appeal that wins usually includes:
Hospital discharge summary showing the qualifying inpatient stay — §30's first factor requires the skilled need be for a condition treated during a prior inpatient hospital stay. (The facility provides this.)Skilled Nursing Facility Level of Care - General
Physician's order for daily skilled nursing or therapy — §30.2.1 requires skilled services furnished pursuant to physician orders, provided or supervised by licensed personnel. (Your doctor's office provides this.)Skilled Services Defined
Nursing/therapy notes showing skilled care was delivered daily — §30's second factor is a daily-basis requirement — records showing only intermittent visits undercut this. (The facility provides this.)Skilled Nursing Facility Level of Care - General
A copy of the plan's own coverage criteria, if the denial cited one — 42 CFR § 422.101(b)(6) requires an MA plan to make its own internal coverage criteria publicly available on request. (Request this from the plan.)42 CFR 422.101
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 condition requiring the SNF stay, and its connection to the prior hospitalization.Skilled Nursing Facility Level of Care - General
Why the specific nursing/therapy services required a skilled provider (registered nurse, licensed therapist) rather than custodial care.Skilled Services Defined
Whether the skilled service was needed daily, and for how many days.Skilled Nursing Facility Level of Care - General
Whether maintaining the patient's current condition or slowing decline — not just improvement — required a skilled level of care.Skilled Services Defined
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
- 42 CFR 422.101as of September 18, 2026
- 42 CFR 422.582as of September 18, 2026
- Skilled Nursing Facility Level of Care - Generalas of September 22, 2026
- Skilled Services Definedas 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.
