How to Appeal a Humana Skilled Nursing Facility Denial

Getting a denial from Humana for a Skilled Nursing Facility claim using CPT code 99304 can be incredibly frustrating, especially when you know the care was medically necessary. You've provided comprehensive documentation, followed all protocols, and then receive that dreaded denial letter stating the service wasn't medically necessary or that the patient was stable for discharge. Unfortunately, Humana denials for Skilled Nursing Facility services (CPT 99304) rank among the most frequently appealed claims in geriatrics, but the good news is that these denials are often overturnable when you present the right clinical evidence and structure your appeal properly.

Why Humana Denies Skilled Nursing Facility

Humana's denial patterns for CPT 99304 typically fall into three primary categories, each reflecting their strict interpretation of Medicare guidelines and their own medical policies.

Medical Necessity Not Established is the most common denial reason you'll encounter. Humana's medical policy requires clear evidence that the patient needs skilled nursing or rehabilitation services that can only be provided in an inpatient setting. They frequently deny claims when documentation doesn't explicitly demonstrate why the patient couldn't receive equivalent care at a lower level, such as home health or outpatient services. The payer scrutinizes whether the documentation shows ongoing skilled care needs beyond basic monitoring.

Patient Stable for Discharge represents Humana's second most frequent denial category for SNF admissions. Their medical reviewers look for evidence that acute medical conditions have stabilized and that the patient no longer requires the intensive monitoring available in skilled nursing facilities. Humana's clinical guidelines emphasize that once vital signs stabilize, pain is controlled, and no active titration of medications is occurring, continued SNF stay may not meet their criteria for coverage.

Custodial Care Not Covered rounds out the top three denial reasons. Humana draws a sharp distinction between skilled care and custodial care, denying claims when they determine the primary services provided are assistance with activities of daily living rather than skilled nursing interventions. Their policy explicitly excludes coverage for services that could be performed by non-medical personnel or family members, even in a SNF setting.

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. Humana wants to see evidence that nursing staff are making clinical decisions and providing care requiring professional training.

Rehabilitation Therapy Documentation becomes crucial when functional improvement potential exists. Physical therapy, occupational therapy, and speech therapy evaluations and progress notes should demonstrate measurable goals and ongoing progress toward functional improvement. Include standardized assessment scores and specific functional outcomes that show improvement potential.

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.

The Centers for Medicare & Medicaid Services' guidelines for SNF coverage, which Humana generally follows, require that services be reasonable and necessary for treatment of illness or injury, which should 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 - Humana requires first-level appeals to be submitted within 60 days of the initial denial date. Mark your calendar immediately upon receiving the denial, as missing this deadline typically results in automatic appeal dismissal. For expedited appeals involving continued stay denials, you have 72 hours to file.

Submit to Correct Department - Send your appeal documentation to Humana's Medical Appeals Department, not general customer service. Include the specific appeal form required for professional services, along with your clinical documentation package. Ensure you're using Humana's current appeal form, as they periodically update requirements.

Structure Your Appeal Letter Strategically - Begin with a clear statement that you're appealing the denial of CPT 99304 for 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 - Humana offers peer-to-peer review opportunities where the attending physician can speak directly with their medical director. This option works particularly well for complex cases where clinical nuances aren't apparent from documentation alone. Request this option in your initial appeal letter to expedite the process.

Track Your Appeal Status - Humana provides online appeal tracking through their provider portal. Monitor status regularly and follow up if you don't receive acknowledgment within 10 business days. They're required to process standard appeals within 30 days and expedited appeals 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 proven argument structures address their most common denial reasons effectively.

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."

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
• File your appeal within 60 days using Humana's required forms and submit to their Medical Appeals Department, not general customer service
• 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 under 2 minutes, matching your clinical documentation to Humana's specific criteria.