Home Health Care Insurance Denial Appeal Guide
Home health care including skilled nursing and therapy is covered by most plans when medically necessary, but insurers frequently deny or limit visits based on improvement standards.
Why Home Health Care Gets Denied
Insurers often deny home health services when they determine the patient is not showing sufficient improvement or when they believe the patient is stable enough to receive outpatient care. The Jimmo v. Sebelius settlement clarified that maintenance therapy must also be covered by Medicare.
Common Denial Reasons
- Patient not homebound (Medicare requirement)
- Not showing improvement (illegal under Jimmo settlement for Medicare)
- Skilled need not documented (aide services require underlying skilled need)
- Visit frequency excessive
- Plan day/visit limits exceeded
How to Appeal
- Document homebound status — for Medicare, leaving home requires considerable effort or is medically contraindicated
- For maintenance therapy — cite Jimmo v. Sebelius: skilled therapy is covered to maintain function, not just improve it
- Document why outpatient is inappropriate — fall risk, transportation barriers, medical complexity
- Get physician order with specific skilled care needs documented
- Detailed nursing/therapy notes showing medical complexity requiring skilled intervention
The Jimmo Settlement
Medicare beneficiaries are entitled to skilled nursing and therapy services to maintain function and prevent decline, not just for improvement. Many denials still incorrectly apply an "improvement standard." Cite the 2013 Jimmo v. Sebelius settlement in your appeal.