Original Medicare denied continued home health care? What the rule says and how to appeal.
Checked against the current rules on September 23, 2026.
A denial for continued home health care isn't the end of the story — Original Medicare has 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 continued home health care under Original Medicare is governed by§ 405.1200 Notifying beneficiaries of provider service terminations. and§ 405.1202 Expedited determination procedures. andPatient Confined to the Home. Original Medicare 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 your parent still considered homebound — able to leave only with difficulty, and rarely?
Is a nurse or therapist still coming to provide skilled care, not just aide visits?
Did a doctor or qualifying practitioner document a face-to-face encounter supporting the ongoing need for care?
What a winning appeal has to show
An appeal that wins usually includes:
A copy of the NOMNC itself, with the printed date and time — Same 72-hour QIO clock and filing deadline as the SNF path — 42 CFR 405.1202. (You or your family provide this.)42 CFR 405.1202
Notes describing why leaving home takes considerable and taxing effort — "Homebound" has a specific meaning under the home health benefit — it doesn't require being bedbound, only that leaving takes real effort or assistance and is infrequent. (You or your family provide this.)
The physician's or qualifying practitioner's face-to-face encounter documentation — This encounter is what's supposed to support both the original certification and any recertification of ongoing need — its absence or vagueness is itself worth raising. (Your doctor's office provides this.)
Your deadline to appeal
By the deadline stated on your notice — see the fast-appeal page for the exact rule for your situation.42 CFR 405.1202
Your Medicare contractor itself then has its own clock to decide. 1 calendar day (observation, hospital discharge) or 72 hours (SNF/home health/hospice ending), once the QIO has what it needs.
What to ask your doctor to address
If you're asking the treating physician for a supporting letter, it should speak to:
Whether the patient remains homebound and still needs skilled home health care.42 CFR 405.1200
Whether the goal is maintaining the patient's condition or slowing decline, even without expected improvement.CMS — Jimmo v. Sebelius Settlement Agreement (D. Vt., approved Jan. 24, 2013)
Questions people ask
- Can your Medicare contractor 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 23, 2026
- § 405.1200 Notifying beneficiaries of provider service terminations.as of September 23, 2026
- § 405.1202 Expedited determination procedures.as of September 23, 2026
- CMS — Jimmo v. Sebelius Settlement Agreement (D. Vt., approved Jan. 24, 2013)
- Patient Confined to the Homeas of January 1, 2010
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.
