Humana Skilled Nursing Facility Denied: Jimmo Settlement, Concurrent Review, and Appeals

Skilled nursing facility care is a critical bridge between hospital discharge and return to home or long-term care — but Humana Medicare Advantage members frequently find SNF claims denied mid-stay or at the outset. The key to appealing these denials is understanding the legal standard that governs SNF coverage (including the landmark Jimmo settlement) and the specific process Humana uses for concurrent review.

What Humana's SNF Coverage Requires

Humana Medicare Advantage covers skilled nursing facility care under criteria that mirror original Medicare's SNF coverage rules (CMS Medicare Benefit Policy Manual, Chapter 8). The basic requirements are:

1. A qualifying inpatient hospital stay: Traditional Medicare requires a preceding inpatient hospital stay of at least 3 consecutive days (not counting the discharge day) before SNF coverage begins. Some Humana MA plans waive this requirement — check your Evidence of Coverage. Days spent in observation status do NOT count toward the 3-day qualifying stay.

2. Medical necessity of skilled nursing or therapy: The SNF admission must be for a condition requiring skilled nursing care or skilled rehabilitation (physical, occupational, or speech therapy). "Skilled" means care that requires the training, knowledge, and judgment of a licensed nurse or therapist — not custodial care (bathing, feeding, dressing) that any caregiver could provide.

3. Physician certification: A physician must certify the need for SNF care and provide a plan of care.

4. Continued medical necessity: Coverage continues only as long as skilled care is medically necessary. This is where most Humana SNF denials occur — through concurrent review during the stay.

The Jimmo v. Sebelius Settlement: Maintenance Care Is Covered

The single most important legal protection in SNF coverage disputes is the Jimmo v. Sebelius settlement (No. 5:11-cv-17, D. Vt. 2013). This landmark case established definitively that:

Medicare — and therefore Humana Medicare Advantage — does NOT require patients to show measurable improvement to qualify for continued SNF coverage.

Coverage is available when skilled nursing or therapy is needed to:

• Maintain the patient's current condition (prevent deterioration), OR
• Slow the rate of decline

This is called the maintenance standard. It means that a patient with a chronic, degenerative condition — Parkinson's disease, ALS, multiple sclerosis, severe dementia — who has "plateaued" and is no longer expected to improve can still qualify for SNF coverage if skilled care is required to maintain their current level of function or prevent deterioration.

If Humana's denial letter contains language suggesting coverage was terminated because you are no longer improving, that is almost certainly a Jimmo violation. Use this language in your appeal: "Under the Jimmo v. Sebelius settlement and CMS's updated Medicare Benefit Policy Manual, coverage of skilled nursing care does not require improvement — it requires only that skilled care is necessary to maintain function or slow decline. The denial applies an improvement standard that CMS has explicitly prohibited."

How Humana Uses Concurrent Review to End SNF Coverage

Humana (typically through C2C Innovative Solutions) conducts concurrent review of SNF stays — an ongoing utilization management process in which Humana reviews your clinical chart during the stay to determine whether continued skilled care is authorized. Common concurrent review denial triggers include:

• Patient has reached a "functional plateau" (improvement standard wrongly applied — cite Jimmo)
• Care has transitioned from skilled to custodial in Humana's assessment
• Therapy frequency has been reduced below Humana's threshold
• Patient has refused certain therapies or is non-compliant (must be assessed carefully — voluntary refusal differs from medically justified modification)
• Physician orders have changed in a way that Humana interprets as reducing skilled care

When concurrent review results in a denial, the facility must give you a Notice of Medicare Non-Coverage (NOMNC). You have the right to immediately appeal this decision to the Quality Improvement Organization (QIO) — a Medicare contractor independent of Humana — before you are discharged. Call 1-800-MEDICARE to identify your regional QIO.

Documentation That Supports Continued SNF Coverage

For continued SNF coverage, your clinical team should document:

• Skilled nursing needs: Wound care, IV medication administration, tracheostomy management, feeding tube management, complex medication regimens requiring nursing assessment
• Skilled therapy needs: Specific functional deficits being addressed, therapy interventions requiring skilled judgment, and measurable therapy goals — even maintenance goals like preventing falls or preserving functional independence
• Why maintenance care requires skilled staff: What would happen if care were discontinued — would the patient deteriorate? Would an unskilled caregiver be unable to safely perform the required care?
• Physician involvement: Active physician oversight, order changes, and assessments showing ongoing medical management

How to Appeal a Humana SNF Denial

For in-stay denials (concurrent review):

• Request the NOMNC and immediately contact the QIO
• The QIO review is free and fast — the QIO must issue a decision before you are required to leave
• Simultaneously file an internal appeal with Humana

For post-discharge denials:

• File a Level 1 internal appeal within 60 days of the denial
• Include complete nursing notes, therapy assessments, physician certification, and plan of care
• Cite Jimmo explicitly if the denial applied an improvement standard
• Submit your appeal to: Humana Grievances and Appeals, P.O. Box 14546, Lexington, KY 40512; or by phone at 1-800-457-4708; or through MyHumana at humana.com

If the internal appeal is denied, escalate to QIC review, then OMHA for an ALJ hearing.

Fight Back With ClaimBack

Humana SNF denials — particularly those that wrongly apply an improvement standard — are among the most successfully overturned claim types on appeal. The Jimmo settlement gives you powerful legal grounds for challenging these decisions. ClaimBack helps you cite the right law and build the right documentation.

Start your appeal at https://claimback.app/appeal.

Related Reading

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