Original Medicare denied skilled nursing or home health because your parent isn't improving? What the rule says and how to appeal.
Checked against the current rules on September 26, 2026.
A denial for skilled nursing or home health because your parent isn't improving 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 skilled nursing or home health because your parent isn't improving under Original Medicare is governed bySkilled Nursing Facility Level of Care - General andNeeds Skilled Nursing Care on an Intermittent Basis (Other than. 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 the goal of this care to maintain the patient's condition or slow decline, rather than to produce further improvement?
Do the specific tasks being performed require a nurse's or therapist's own training to do safely — not just something a family member could learn to do?
What a winning appeal has to show
An appeal that wins usually includes:
Documentation of the specific skilled tasks being performed and why they require a nurse's or therapist's training — The Jimmo v. Sebelius settlement confirms coverage doesn't require potential for improvement — maintenance and slow-deterioration-prevention skilled care can qualify too. (The facility provides this.)CMS — Jimmo v. Sebelius Settlement Agreement (D. Vt., approved Jan. 24, 2013)
Notes on what's likely to happen to the patient's condition if the skilled service stopped — Showing the real risk of decline or complication without the skilled service directly supports the maintenance standard, separate from any improvement question. (Your doctor's office provides this.)
Your deadline to appeal
120 days from the date on the Medicare Summary Notice — 120 calendar days from when you receive it (42 CFR § 405.942(a)), with receipt presumed to be 5 days after the notice's own date unless shown otherwise.42 CFR 405.942
Your Medicare contractor itself then has its own clock to decide. 60 calendar days from when the MAC receives your timely request. Each time you submit new evidence after filing, that 60-day clock is extended by up to 14 more calendar days for that submission (42 CFR § 405.950(a), (b)(3)) — this can happen more than once.
What to ask your doctor to address
If you're asking the treating physician for a supporting letter, it should speak to:
Whether skilled care is needed to maintain the patient's current condition or slow further decline, even without expected improvement.CMS — Jimmo v. Sebelius Settlement Agreement (D. Vt., approved Jan. 24, 2013)
What would likely happen to the patient's condition without the continued skilled service.
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 26, 2026
- 42 CFR 405.942as of September 23, 2026
- CMS — Jimmo v. Sebelius Settlement Agreement (D. Vt., approved Jan. 24, 2013)
- Needs Skilled Nursing Care on an Intermittent Basis (Other thanas of January 1, 2010
- Skilled Nursing Facility Level of Care - Generalas of September 26, 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.
