Aetna Denied Skilled Nursing Facility Coverage? How to Appeal

Skilled nursing facility (SNF) denials are among the most harmful insurance coverage decisions — they affect patients who are often elderly, recovering from major surgery or illness, and physically unable to advocate for themselves. Aetna applies strict criteria to SNF admissions, continued stays, and therapy services, but these denials can be successfully appealed with the right approach.

Aetna's SNF Coverage Criteria

Aetna, a CVS Health subsidiary covering approximately 23 million medical members, requires the following for SNF coverage under most commercial plans and Medicare Advantage:

• Qualifying inpatient hospital stay: For Medicare Advantage members, a 3-day inpatient hospital stay (not observation) is typically required before SNF coverage begins. Observation stays do not count toward this requirement.
• Skilled care requirement: The patient must need care that requires the skills of a licensed nurse or registered therapist — not just custodial or supervisory care.
• Daily skilled care: Traditional Medicare (and most MA plans) require that skilled care be needed on a daily basis.
• Reasonable and necessary: The care must be expected to improve the patient's condition or maintain a level of function.

Aetna uses MCG Health criteria to evaluate SNF necessity, including admission criteria, intensity of service criteria, and discharge readiness criteria.

The "Improvement Standard" Myth

One of the most widespread misconceptions — and a significant source of wrongful SNF denials — is that Medicare and Aetna Medicare Advantage only cover skilled care when the patient is expected to improve. This is legally incorrect.

The landmark Jimmo v. Sebelius settlement (2013) established that Medicare covers skilled nursing and therapy services needed to maintain a patient's current level of function or to prevent decline — even when no improvement is expected. This applies to patients with Parkinson's disease, ALS, severe stroke, advanced dementia, and other conditions where maintenance is the appropriate goal.

If Aetna denied your SNF coverage or therapy services on the grounds that you weren't "making progress" or weren't expected to improve, cite Jimmo v. Sebelius directly in your appeal. CMS has repeatedly issued guidance reminding MA plans that the improvement standard cannot be applied.

Maintenance Therapy Appeals

If Aetna terminated SNF therapy services because your therapist documented "plateau" or "maintenance," your appeal should include:

• Therapist's letter documenting what skilled services are required to maintain function
• Decline documentation: Evidence that without skilled maintenance therapy, the patient would deteriorate
• Jimmo citation: Explicit reference to the Jimmo settlement and CMS guidance
• Functional assessment scores: Before and after therapy, and projected decline without continued skilled services

The SNF therapist and physician must document why the ongoing services require the skills of a licensed therapist — not just supervision or instruction that a family member or aide could provide.

SNF Discharge Denials: Your Right to Stay

If Aetna issues a notice that SNF coverage will end (typically via an NOMNC — Notice of Medicare Non-Coverage for MA members), you have the right to an expedited appeal. This is separate from a standard appeal and must be filed before coverage ends.

For Medicare Advantage members:

• Request an expedited appeal through Aetna immediately upon receiving the NOMNC
• Contact your state's Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) for an independent second opinion
• Aetna must respond to an expedited SNF discharge appeal within 72 hours

During the appeal, coverage continues until the decision is made. You cannot be discharged while an expedited appeal is pending.

Documenting Your SNF Appeal

Build a strong SNF appeal with:

1. Hospital discharge summary and the admitting diagnosis
2. SNF admission assessment (MDS/Minimum Data Set) and care plan
3. Therapy evaluation notes documenting functional status and treatment goals
4. Physician orders for skilled care with clinical rationale
5. Progress notes or, for maintenance cases, documentation of the skilled services required
6. Letter from attending physician addressing why continued SNF care is medically necessary

How to File an Aetna SNF Appeal

• Phone: 1-800-537-9384 (request expedited review for active denials)
• Online: my.aetna.com
• Written: Aetna Appeals, P.O. Box 981106, El Paso, TX 79998

For Medicare Advantage SNF denials, you may also file with the Medicare Independent Dispute Resolution process. Aetna uses Maximus Federal Services as its primary external IRO.

Fight Back With ClaimBack

SNF denials based on the improvement standard are legally improper under Jimmo v. Sebelius. ClaimBack helps you build a maintenance-of-function argument that directly addresses Aetna's criteria and the legal framework governing skilled care coverage.

Start your Aetna SNF appeal at ClaimBack

Related Reading

• What Is Medical Necessity?
• How to Write an Insurance Appeal Letter
• Internal vs. External Insurance Appeals