Start with the denial and clinical records.

Purpose

This letter requests expedited reconsideration of the termination of Medicare Part A SNF coverage for the above-named beneficiary, scheduled to end on 04/15/2026 per the Notice of Medicare Non-Coverage dated 04/12/2026. The beneficiary continues to require daily skilled services that meet coverage criteria under the Medicare Benefit Policy Manual, and we request that coverage be continued to allow completion of the current plan of care.

Clinical summary

Ms. J.R. is an 86-year-old admitted to our facility on 03/20/2026 following open reduction and internal fixation of a left hip fracture. At the time of NOMNC issuance, she remains on a daily plan of skilled rehabilitation and skilled nursing services. Current physical therapy documentation shows the patient ambulating 50 feet with rolling walker and contact guard assist, requiring skilled cueing for hip precautions and gait pattern1. MDS 3.0 Section GG scoring confirms ongoing partial-to-substantial assistance needs for functional mobility and transfers5.

Skilled nursing documentation from 04/11/2026 reflects a non-healed surgical incision with a 1 cm area of delayed closure and peri-wound erythema requiring ongoing skilled assessment for signs and symptoms of infection2. Morse Fall Scale scoring of 65/125 places the patient at high fall risk6, and the plan of care continues to require skilled nursing interventions for fall prevention and medication management.

Policy support

Per Medicare Benefit Policy Manual, Chapter 8, §30.2.2, a service is properly considered skilled when its inherent complexity is such that it can be performed safely and effectively only by or under the supervision of qualified technical or professional personnel3. Skilled gait training under hip precautions, wound assessment of a non-healed surgical site, and fall-risk management for a patient with documented functional deficits meet this standard on their face.

The Jimmo v. Sebelius settlement further clarifies that coverage of skilled care does not turn on the presence or absence of improvement potential; rather, it turns on the beneficiary's need for skilled care to maintain function or to prevent or slow further deterioration4. The stated denial reason — that the beneficiary "has plateaued" — is not a basis for termination under Jimmo where, as here, continued skilled services are necessary to maintain current function and prevent decline.

Risk of premature termination

Discontinuation of services at this juncture presents concrete and foreseeable risks: (i) the patient remains below the functional threshold for safe household ambulation and has not yet achieved independence with hip precautions; (ii) the surgical incision has not fully closed and continues to require clinical surveillance; and (iii) the patient remains at documented high fall risk. Premature termination is reasonably likely to precipitate a fall, wound complication, or rehospitalization — each of which would reverse the functional gains achieved during this stay and increase total program cost.

Request

Based on the clinical documentation attached and the coverage standards cited above, we respectfully request that the Quality Improvement Organization overturn the termination and reinstate Medicare Part A SNF coverage to allow continuation of the current skilled plan of care. We will provide any additional information the QIO requires by close of business of the day of request, in accordance with 42 C.F.R. § 405.1202.