The Jimmo settlement: Medicare doesn't require improvement for skilled care
"Your parent isn't improving" is one of the most common — and most often wrong — reasons families are given for a denial of skilled nursing, home health, or outpatient therapy.
Source: Jimmo v. Sebelius settlement (CMS).
The Jimmo v. Sebelius settlement, approved by a federal court in 2013, confirmed what the coverage rules already said: skilled care is covered when it takes a nurse's or therapist's own training to perform safely and effectively — whether or not the patient is expected to improve.CMS — Jimmo v. Sebelius Settlement Agreement (D. Vt., approved Jan. 24, 2013)
Maintaining a patient's current condition, or slowing further decline, can qualify for skilled coverage exactly the same way care aimed at improvement does — there's no separate, stricter "improvement standard" in the actual rule.
What this means for your appeal
A denial that says care isn't covered because the patient "isn't improving" or has "plateaued" is often applying a standard the settlement specifically rejected — worth naming directly in your appeal.
The real question is whether the specific tasks being performed require a nurse's or therapist's own skill and training — not whether the patient's condition is getting better.
This applies to skilled nursing facility care too
The settlement isn't limited to home health or outpatient therapy — the same maintenance standard governs skilled nursing facility coverage under Medicare's own SNF benefit manual chapter.CMS — Jimmo v. Sebelius Settlement Agreement (D. Vt., approved Jan. 24, 2013)
As part of the settlement, CMS committed to revising its own coverage manuals and running a nationwide education campaign specifically so contractors and reviewers stop applying an improvement requirement that was never actually in the rule — citing the resulting manual language directly, not just the settlement itself, is often the more persuasive move.
What to document for a maintenance-care appeal
Ask the treating clinician to state directly, in writing, why the specific service requires a skilled nurse's or therapist's own judgment to perform safely — not just that the patient benefits from it, since Medicare doesn't cover services a family member could safely provide.
A record showing the patient's condition would likely decline or the risk of complications would increase without the skilled service is exactly the kind of documentation this standard asks for, whether or not the patient is expected to improve.
If a denial notice or MSN uses words like "no progress" or "condition stable, no further skilled need," ask the redetermination reviewer directly to apply the maintenance standard — naming Jimmo by name in the request is a real, citable way to make sure the right standard actually gets applied.
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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.
