[DATE — FILE TODAY] To: BFCC-QIO — [REQUIRED: identify the BFCC-QIO for Florida — Livanta LLC serves Florida Medicare beneficiaries] Attn: Expedited Appeal — SNF Coverage Termination Re: Expedited Appeal of Notice of Medicare Non-Coverage (NOMNC) Beneficiary: [REQUIRED: Patient full name] Medicare/Humana MA ID: [REQUIRED: Medicare number from red, white, and blue card] SNF Facility: [REQUIRED: SNF name and address] Coverage Termination Date: February 23, 2026 (Day 21) To the BFCC-QIO Review Team, I am writing on behalf of [patient name], a 72-year-old Medicare Advantage beneficiary enrolled in Humana, to formally appeal the Notice of Medicare Non-Coverage (NOMNC) dated [REQUIRED: date of NOMNC] terminating skilled nursing facility coverage effective February 23, 2026. This appeal is submitted on the following grounds: 1. THE JIMMO STANDARD — HUMANA IS APPLYING THE WRONG LEGAL STANDARD Humana's termination notice cites that the patient is "no longer making measurable progress." This is not the correct legal standard for Medicare SNF coverage. The settlement agreement in Jimmo v. Sebelius (D. Vt. 2013), which binds Medicare Advantage plans, establishes that skilled care coverage cannot be terminated solely because a beneficiary is not improving, if skilled care is required to maintain the beneficiary's current level of function or to prevent or slow further deterioration. This patient requires skilled nursing facility care not only to achieve further functional improvement — which she is demonstrably achieving — but also to maintain her current gains and prevent the functional regression that would result from discharge to home without adequate skilled support at this stage of stroke recovery. 2. THE PATIENT IS DEMONSTRABLY MAKING PROGRESS The termination notice states there is a "plateau in progress." The clinical record directly contradicts this determination: ▸ Physical therapy: Ambulation improved from 0 feet at admission (required total assist) to 20 feet with rolling walker and moderate assist as of [REQUIRED: date of last PT note]. Goal: 50 feet by discharge. ▸ Occupational therapy: Transfer status improved from total assist to moderate assist. ADL performance improved from total dependence to moderate assist for bathing and dressing. [REQUIRED: document specific OT progress metrics] ▸ Speech-language pathology: Word-finding success rate improved from 10% at admission to 30% as of [REQUIRED: date of last SLP note]. Swallowing safety improved — diet upgraded from puree to minced and moist. [REQUIRED: document specific SLP progress metrics] These are measurable, documented functional gains. The determination that progress has "plateaued" is not supported by the clinical record. 3. DISCHARGE AT THIS STAGE CREATES SIGNIFICANT SAFETY RISK This patient is 21 days post-ischemic stroke. Discharge to home at this functional level — requiring moderate assist for all transfers, unable to ambulate safely without supervision, with expressive aphasia limiting communication of needs — creates immediate and foreseeable safety risk including fall, aspiration, and functional regression. The SNF skilled team is the appropriate level of care. Discharge is clinically premature. I respectfully request that the BFCC-QIO conduct an immediate expedited review of this termination and issue a determination that Humana's coverage termination is not valid under applicable Medicare coverage standards. [REQUIRED: Patient signature OR authorized representative signature with POA documentation] [REQUIRED: Contact information for patient/representative] [REQUIRED: Attach all therapy progress notes from admission to present] [REQUIRED: Attach physician orders and most recent clinical summary from SNF]