Humana Denied Skilled Nursing? Appeal Guide + Free Template (2026)

A Humana denial for skilled nursing facility (SNF) care usually says the stay was not medically necessary, the patient was stable for discharge, or the care was custodial. Two different claims can be involved. The facility bills the stay on an institutional claim. CPT 99304 is not the stay: it is one of the codes for the physician's or other practitioner's initial visit with a patient in a nursing facility, billed on a separate professional claim. This guide covers level-of-care denials of the stay; a denial of the practitioner's visit is appealed on its own claim. For Humana Medicare Advantage members, the plan must follow Medicare's SNF coverage rules where Medicare's criteria are fully established (42 CFR 422.101).

Why Humana Denies Skilled Nursing Facility

Level-of-care denials for a SNF stay typically fall into three categories.

Medical Necessity Not Established is the most common denial reason you'll encounter. Medicare's SNF level-of-care rules require that the patient need skilled nursing or skilled rehabilitation services on a daily basis, and that those daily services, as a practical matter, can only be provided in a SNF on an inpatient basis (42 CFR 409.31). Denials follow when the documentation does not show why the patient could not receive the care at a lower level, such as home health or outpatient services, or does not show daily skilled needs beyond basic monitoring.

Patient Stable for Discharge denials say the patient no longer needs daily skilled services. Reviewers look at whether acute conditions have stabilized, pain is controlled and medications are no longer being adjusted. Stability alone does not end coverage under Medicare's rules: skilled care to maintain the patient's condition or slow decline is covered when it needs a skilled professional (Jimmo v. Sebelius settlement, 2013). The question is whether the patient still needs daily skilled services.

Custodial Care Not Covered rounds out the top three denial reasons. Medicare excludes custodial care, which its regulations define as care that does not meet the SNF coverage requirements (42 CFR 411.15(g)). These denials say the primary services were help with activities of daily living rather than skilled nursing or therapy, so the record has to show the skilled interventions, not only assistance with bathing, dressing, eating or moving.

What You Need to Win This Appeal

Successfully overturning a Humana SNF denial requires assembling comprehensive clinical documentation that directly addresses their medical necessity criteria. Your appeal strength depends on presenting the right evidence in a format that clearly demonstrates ongoing skilled care needs.

Physician Documentation and Orders form the foundation of your appeal. You need detailed physician notes that specify why SNF-level care remains necessary, including current medical conditions requiring skilled intervention, medication management complexity, and functional deficits that necessitate professional nursing supervision. Ensure physician orders clearly indicate skilled nursing services rather than custodial care activities.

Skilled Nursing Documentation must demonstrate daily skilled interventions beyond basic monitoring. Include nursing assessments showing medication administration requiring clinical judgment, wound care documentation, monitoring of unstable medical conditions, or management of medical equipment. Show that nursing staff are making clinical decisions and providing care that requires professional training.

Rehabilitation Therapy Documentation matters whether the goal is improvement or maintenance. Physical therapy, occupational therapy, and speech therapy evaluations and progress notes should state measurable goals and why each service needs a skilled therapist. Include standardized assessment scores and functional outcomes. If the goal is to maintain function or prevent decline, say so; Medicare coverage does not depend on improvement when the care needs a skilled professional (Jimmo v. Sebelius settlement, 2013).

Clinical Indicators Supporting Medical Necessity should include recent vital sign trends, laboratory values, diagnostic test results, and medication adjustments that demonstrate ongoing medical instability or complexity. Pain assessment scores, cognitive evaluation results, and fall risk assessments can support the need for skilled supervision.

Medicare's SNF coverage rules, which Humana Medicare Advantage plans must follow where Medicare's criteria are fully established, require that services be reasonable and necessary for the treatment of illness or injury; use them to guide your documentation review.

Step-by-Step: Appealing Your Humana Skilled Nursing Facility Denial

Humana maintains specific procedural requirements for SNF appeals that must be followed precisely to ensure your appeal receives proper consideration. Understanding their process and deadlines prevents automatic dismissals due to procedural errors.

File Within Required Timeframes - For a Humana Medicare Advantage member, the enrollee (or a non-contracted facility with a waiver of liability) has 65 days from the notice to request reconsideration of a denied stay or claim, and a reconsideration the plan upholds is forwarded automatically to the Independent Review Entity. A contracted facility's payment dispute follows its contract. When the plan ends covered SNF care, the facility must give the enrollee a Notice of Medicare Non-Coverage no later than two days before coverage ends, and the enrollee can ask the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) named on the notice for a fast-track review, due by noon of the day before coverage ends when the notice was delivered on time (42 CFR 422.624, 42 CFR 422.626, CMS NOMNC page). Check the contract and the denial notice for the deadline that applies, and calendar it the day the denial arrives.

Submit to Correct Department - Send the appeal to the address or portal named on the denial notice, not general customer service. If Humana requires a specific appeal or dispute form for the claim type, use the current version, and attach your clinical documentation package.

Structure Your Appeal Letter Strategically - Begin with a clear statement of what you are appealing (the denied SNF days, or the practitioner's visit billed with CPT 99304) and the specific dates of service. Reference the original claim number and denial reason. Organize your clinical argument to directly address the stated denial reason, whether medical necessity, stability for discharge, or custodial care determination.

Request Peer-to-Peer Review - Ask early whether the attending physician can discuss the case with the plan's physician reviewer; the denial notice or provider portal explains whether this is available and how soon it must be requested. It is separate from the written appeal, so keep the appeal on its own deadline.

Track Your Appeal Status - Keep a dated record of every submission and follow up if you do not receive an acknowledgment. For Medicare Advantage reconsiderations, standard pre-service requests are decided within 30 days, payment requests within 60 days and expedited requests within 72 hours.

Sample Appeal Arguments for Skilled Nursing Facility Denials

Crafting compelling clinical arguments requires connecting your patient's specific clinical picture to Humana's coverage criteria. These argument structures address their most common denial reasons.

For Medical Necessity Denials: "The patient requires skilled nursing facility level care due to complex medication management requiring professional nursing assessment and intervention. Daily monitoring of cardiac medications with frequent dose adjustments based on vital sign parameters and clinical response necessitates skilled nursing supervision. The patient's multiple comorbidities including congestive heart failure, diabetes with brittle glucose control, and chronic kidney disease create medication interactions requiring clinical judgment that exceeds the scope of custodial care or home health services."

For Stability Arguments: "While the patient's acute condition has improved, ongoing medical instability requiring skilled intervention persists. Blood pressure medications require continued titration based on daily assessments, wound care involves complex dressing changes requiring sterile technique and clinical assessment for signs of infection, and physical therapy for functional improvement following acute illness requires skilled supervision due to cardiac limitations and fall risk."

For Custodial Care Determinations: "The services provided constitute skilled nursing care as defined by Medicare guidelines, not custodial care. Daily clinical assessments are required to monitor for complications of chronic conditions, medication administration involves clinical decision-making regarding timing and dosing based on patient response, and functional training provided by therapy staff requires professional expertise due to safety concerns and medical complexity."

For Functional Improvement Arguments: "The patient demonstrates clear potential for functional improvement with continued skilled intervention. Physical therapy documentation shows measurable progress in mobility scores, and occupational therapy notes indicate advancing independence in activities of daily living. The rehabilitation potential combined with medical complexity necessitates SNF-level care coordination that cannot be safely provided at lower levels of care."

Appeal letter template

Fill in the bracketed fields from the denial letter and the chart, and delete any paragraph that does not apply.

[Facility name]
[Facility address]
[Phone and fax]

[Date]

Humana, [appeals or dispute unit named on the denial letter]
[Appeals address or fax number from the denial letter]

Re: [Patient name], member ID [member ID], claim number [claim number], skilled nursing facility stay from [first denied day] to [last denied day], codes [codes on the denied claim]

Dear Appeals Reviewer,

We request reconsideration of Humana's denial of the skilled nursing facility days listed above. The denial dated [denial date] states [denial reason as written in the denial letter]. The enclosed records show that the patient needed daily skilled services on each denied day.

From [first date] to [last date], [patient name] needed daily skilled [nursing, rehabilitation or both] services: [skilled interventions, such as medication management requiring clinical judgment or wound care]. [Therapy services, with measurable goals and why each needed a skilled therapist.] As a practical matter, these daily services could only be provided in a SNF on an inpatient basis, because [why home health or outpatient care could not meet the need]. The record shows skilled care, not only help with bathing, dressing, eating or moving: [examples with dates].

[If the denial says the patient was stable for discharge:] Although [condition] had [improved or stabilized], the patient still needed daily skilled services because [reason]. [If the goal was maintenance, why the care needed a skilled professional.]

The denial cites [policy name and number, if the denial cites one]. [For a Medicare Advantage member: Medicare's SNF level-of-care rules, 42 CFR 409.31.] [Each criterion, and where the enclosed record meets it.]

We ask Humana to reverse the denial and pay the denied days.

Enclosures:

• Denial letter dated [date]
• Physician notes and orders for skilled services
• Daily skilled nursing documentation
• Therapy evaluations and progress notes with goals and standardized scores
• Vital sign trends, lab values, diagnostic results and medication changes
• Pain, cognitive and fall risk assessments

Sincerely,

[Name and credentials]
[Title]
[Facility name]
[Phone and email]

Key Takeaways

• Address Humana's specific denial reason directly with clinical evidence that demonstrates why SNF-level care remains medically necessary rather than custodial
• Compile comprehensive skilled nursing documentation showing daily clinical interventions requiring professional nursing judgment and expertise
• Check the contract and the denial notice for the deadline (65 days for a Medicare Advantage enrollee reconsideration; noon of the day before coverage ends for a fast-track review of a SNF discharge) and submit to the address the notice names
• Consider requesting peer-to-peer review for complex cases where direct physician communication can clarify clinical nuances not apparent in documentation

Tools like AI-powered appeal generators can draft your Skilled Nursing Facility appeal letter in a few minutes, citing Humana's policy when one is on file, for your team to review and send.