This is what CaseWhy Appeals writes for a case like this one; your letter uses your facts and your notice's rule.
September 27, 2026
Sunrise Medicare Advantage — Appeals Department, PO Box 5500, Tampa, FL 33601 — Fax (813) 555-0199
RE: Requesting a standard reconsideration of the plan's payment determination under 42 CFR § 422.578 — Dorothy Sample, plan member ID ••••DEMO, denial dated 2026-08-03, Skilled nursing facility (SNF) level of care
On 2026-08-03, your plan denied the item or service described below. The stated reason was: "The patient has reached maximum benefit from skilled therapy services."
I am appealing your plan's denial based on the stated reason that the beneficiary had "plateaued" and no longer needed daily skilled care. However, BPM Chapter 8 § 30.2.1 explicitly provides that skilled care may be necessary to maintain a patient's current condition or to prevent or slow further deterioration of the patient's condition—not solely to improve it. Your plan's rationale conflates the presence of improvement with the presence of skilled need, which directly contradicts the governing Medicare rule. The regulation states that coverage of nursing care and therapy to perform a maintenance program does not turn on potential for improvement, but rather on the beneficiary's need for skilled care. Therefore, a determination that the patient has plateaued cannot, standing alone, support a finding that daily skilled services are no longer required.
Under BPM Chapter 8 § 30, a stay in a skilled nursing facility is covered when all four factors are met, including that the patient requires skilled services on a daily basis and that, as a practical matter considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis. Your plan's denial fails to distinguish between the absence of improvement and the absence of a daily skilled need. The governing rule requires your plan to evaluate whether the beneficiary continues to require daily skilled services for maintenance, monitoring, or prevention of deterioration—not whether the beneficiary is improving. I respectfully request that your plan reconsider this denial in light of the actual regulatory standard for skilled care coverage.
The facts as I understand them:
There was a hospital stay right before this nursing home stay for a related medical condition.
The nursing home's own records show skilled nursing or therapy happening every day, not just a few times a week.
The denial said the patient plateaued, isn't improving, or has reached maximum benefit.
Requesting a standard reconsideration of the plan's payment determination under 42 CFR § 422.578
I ask that, if this reconsideration involves a question of medical necessity, it be decided by a physician with expertise appropriate to the service at issue, as required.
I understand that if this reconsideration does not fully reverse the original denial, the plan is required to automatically forward this case to the Independent Review Entity.
The amount still in dispute for this claim is $4180.00.
Enclosures:
Physician letter (to follow)
Signed by the enrollee's representative, per the attached Appointment of Representative (CMS-1696).