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Home Health Care Denial: How to Appeal

By AppealFlow editorial•5 min read•
Home Health Care Denial: How to Appeal
Home health denials usually say you're not homebound, don't need skilled care, or aren't improving. For Medicare, you qualify if a doctor certifies you're homebound and need part-time skilled nursing or therapy under a plan of care, and the Jimmo settlement confirms coverage can't be denied just because you've stopped improving. If services are ending, you should get a written notice, and you can request a fast appeal from the BFCC-QIO before the last covered day.

What Does Medicare Require for Home Health?

Key Takeaway: These are the main tests reviewers apply.

  • Homebound: leaving home takes considerable and taxing effort, or requires help, a device, or is medically inadvisable. You can still leave for medical visits, religious services, adult day care and occasional short trips.
  • Skilled need: you need intermittent skilled nursing, physical therapy, speech therapy or continuing occupational therapy.
  • A doctor or allowed practitioner has certified need after a face-to-face encounter and set up a plan of care.
  • The agency is Medicare-certified.

Can Coverage End Because I'm Not Improving?

Key Takeaway: No, not under Medicare rules.

The 2013 Jimmo v. Sebelius settlement confirmed that Medicare covers skilled care needed to maintain your condition or slow decline, not just to improve it. Denials that say you've "plateaued" or have "no improvement potential" are worth challenging; cite Jimmo and ask your therapist or nurse to explain why skilled care is needed to maintain function. Medicare Advantage plans must also follow this standard.

How Do I Appeal When Services Are Ending?

Key Takeaway: Speed matters here.

  • Original Medicare and Medicare Advantage patients should receive a Notice of Medicare Non-Coverage at least two days before covered services end.
  • Call the BFCC-QIO listed on the notice by noon of the day before services end to request a fast appeal; services usually continue while it's reviewed.
  • Ask your doctor for a statement of why skilled care is still needed and what will happen without it.
  • If you miss the fast-appeal window, you can still file a standard appeal.
  • For private plans, file an expedited internal appeal if a delay could seriously harm your health. See expedited appeals.

How Do I Appeal a Denied Start of Care?

Key Takeaway: Build the record around homebound status.

Ask the doctor to document specifics: how far you can walk, need for a walker or another person, shortness of breath, recent hospitalization, fall risk. Vague notes like "patient is weak" are a common reason for denial. Include the face-to-face encounter note and the plan of care with your appeal, and draft the cover letter with the free appeal letter generator.

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Disclaimer: This article is for educational purposes only and does not constitute medical, legal, or financial advice. Plan terms, state laws, and federal rules vary and change. Check your plan documents and denial notice, and consider a licensed professional or your state consumer assistance program. See our full disclaimer.