How to appeal a denial for inpatient rehab

An inpatient rehabilitation facility, or IRF, is for people recovering from a serious surgery, illness or injury who need an intensive rehabilitation therapy program, physician supervision, and coordinated care. Medicare counts it as inpatient hospital care.

Under Medicare’s rule, 42 CFR 412.622(a)(3), there must be a reasonable expectation at the time of admission that you:

1. Need active and ongoing therapy from more than one discipline: physical therapy, occupational therapy, speech-language pathology, or prosthetics and orthotics, one of which must be physical or occupational therapy.
2. Need, and can take part in, an intensive program, which generally means at least 3 hours of therapy a day, at least 5 days a week. In well-documented cases it can be at least 15 hours a week instead.
3. Are stable enough to take part in that program.
4. Need supervision by a rehabilitation physician, who must see you face to face at least 3 days a week.

The IRF must also complete a preadmission screening within 48 hours before you are admitted, and that screening serves as the basis for deciding whether you qualify. Ask for a copy.

Medicare Advantage plans must follow Traditional Medicare’s coverage rules, and the regulation names the IRF criteria in 412.622(a)(3) specifically. These provisions apply to coverage beginning January 1, 2024.

Plans must base medical-necessity decisions on your medical history, your doctors’ recommendations and clinical notes. They may add criteria of their own only where Medicare’s are not fully established, and must publish any they use.

In a February 2024 memo, CMS said that when a doctor orders post-acute care in a specific type of facility and the patient meets Medicare’s criteria for it, the plan “cannot deny admission to that post-acute setting and/or redirect the care to a different setting.”

Plans may offer alternatives, and you may choose one. But CMS added that this flexibility “does not replace the obligation” to cover care that meets Traditional Medicare’s criteria.

In 2022, the Office of Inspector General at the Department of Health and Human Services reviewed a sample of Medicare Advantage denials from 2019. It found that “among the prior authorization requests that MAOs denied, 13 percent met Medicare coverage rules,” and named inpatient rehabilitation among the examples.

A June 2026 follow-up looked at requests from June 2024. “When enrollees appealed, MAOs collectively overturned 36 percent of LTCH denials and 43 percent of IRF denials,” the inspector general wrote, referring to long-term care hospitals and IRFs.

IRF overturn rates ranged from 14 to 86 percent depending on the plan. A KFF analysis of the same data put the share of IRF requests that were initially denied at 54 percent.

These figures describe plans overall and cannot predict your case. They do show that plans reversed a large share of IRF denials when patients appealed.

If the denial comes while you are still in the acute-care hospital, call the plan the same day and ask for a fast appeal.

• Medicare Advantage. Ask for an expedited reconsideration by phone or in writing. If a physician says the standard timeline could seriously jeopardize your health or your “ability to regain maximum function,” the plan must expedite and decide within 72 hours. If it upholds the denial, it must send the case to an independent reviewer within 24 hours.
• Employer and Marketplace plans. Ask for an urgent appeal, which must be decided within 72 hours. In urgent cases you can request external review at the same time.
• Original Medicare. Prior authorization is rarely used. IRFs in Alabama, Pennsylvania, Texas and California take part in a CMS review program, and you may get decision letters in the mail. CMS says “These letters are for your information only – you don’t need to take any action.” The program expands on January 1, 2027 to all IRFs that bill one regional Medicare contractor, including those in Georgia and Tennessee.

Ask the hospital what happens to your discharge while the appeal is pending.

If the hospital says you no longer need inpatient hospital care and you disagree, Medicare patients can also file the separate fast discharge appeal described on the hospital stay page. That appeal decides whether you still need hospital care. It does not decide the IRF request.

• Therapy evaluations from the hospital (physical, occupational and speech) showing which disciplines you need and how much therapy you can tolerate each day.
• Notes on how you functioned before the illness or injury, how you function now, and the goals the team expects you to reach.
• Physician notes explaining why your medical needs call for a rehabilitation physician’s oversight.
• The IRF’s preadmission screening and its acceptance.
• A letter from your attending physician or a rehabilitation physician that addresses each of the four criteria above.
• The denial letter and the criteria the plan cited. If it names a guideline you cannot find, ask the plan for a copy.

Make the letter answer the exact reason in the denial. If the plan says you could not tolerate 3 hours of therapy a day, for example, the therapy notes should show what you actually did each session.

A skilled nursing facility, or SNF, provides skilled nursing care and therapy services on a daily basis. Accepting a SNF is your choice. Before you agree, ask the plan in writing what happens to your IRF appeal if you transfer while it is pending.

Different appeal rules apply in a SNF. When covered SNF care is ending, you should get a Notice of Medicare Non-Coverage at least 2 days before. You can ask the BFCC-QIO for a fast appeal by noon of the day after the notice is delivered in Medicare Advantage, or by noon of the day after you receive it in Original Medicare.

These fast-track rules cover home health agencies, SNFs and comprehensive outpatient rehabilitation facilities, plus hospice in Original Medicare. IRFs are not on that list. Because the hospital discharge rules cover any facility providing inpatient hospital-level care, “acute or non acute,” ask an IRF for the Important Message from Medicare if you are told your stay there is ending.

For SNF, home health and outpatient therapy, the 2013 Jimmo settlement confirmed that coverage depends on your need for skilled care, not your potential for improvement. IRF coverage works differently: its criteria look for measurable improvement of practical value. And CMS has told Medicare Advantage plans that a predicted length of stay cannot by itself be the basis for ending post-acute care.