Original Medicare denied continued skilled nursing or rehab care? What the rule says and how to appeal.
Checked against the current rules on September 26, 2026.
A denial for continued skilled nursing or rehab 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 skilled nursing or rehab care under Original Medicare is governed by§ 405.1200 Notifying beneficiaries of provider service terminations. and§ 405.1202 Expedited determination procedures. andSkilled Nursing Facility Level of Care - General. 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:
Does the NOMNC state the exact date your skilled nursing/rehab services are ending?
Is your parent still receiving skilled nursing or therapy there right now, not just custodial care?
Is the goal of the remaining care to maintain your parent's condition or slow decline, rather than produce further improvement?
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 — The QIO's own 72-hour clock and your filing deadline both run from this notice's printed date — 42 CFR 405.1202. (You or your family provide this.)42 CFR 405.1202
Recent nursing/therapy notes showing ongoing skilled care — The QIO's review turns on whether skilled care is still medically necessary right now, not on the facility's own coverage decision alone. (The facility provides this.)42 CFR 405.1200
Notes on whether the care maintains function or slows decline, not just whether it improves it — The Jimmo v. Sebelius settlement confirmed skilled care doesn't require an expectation of improvement to be covered — maintaining current function or slowing decline can qualify too, as long as a nurse's or therapist's own training is genuinely needed. (The facility provides this.)CMS — Jimmo v. Sebelius Settlement Agreement (D. Vt., approved Jan. 24, 2013)
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 skilled nursing or therapy is still medically necessary, and why.42 CFR 405.1200
What would likely happen to the patient's condition if the skilled service stopped now.
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
- § 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)
- 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.
