Humana “Buyer Beware”: Inpatient Rehabilitation Denials and Medicare Advantage Plans

Case Diagnosis: Lower extremity amputations

Case Description or Program Description: These cases highlight Humana’s divergence from Medicare Guidelines leading to inappropriate patient care.

Setting: Inpatient Rehabilitation Facility

Assessment/Results: The Centers for Medicare & Medicaid Services (CMS) provide clear guidelines for Inpatient Rehabilitation (IPR) eligibility, including 13 qualifying diagnoses such as strokes, spinal cord injuries, brain injuries, and amputations. Medicare Advantage plans must follow these guidelines when considering IPR admissions. We present two cases where Humana deviated from CMS guidelines, delaying or denying appropriate care.

Discussion (relevance): In case one, a patient with a right below-knee amputation was recommended for inpatient rehabilitation (IPR) by the Physiatry consultant. Humana denied admission, and a peer-to-peer review upheld the decision. The reviewing physician admitted to having only a brief summary of the case, lacking key notes despite their submission. She made remarks such as, “I am tasked with gatekeeping,” “I would love to say yes, but I have to get a paycheck,” and “Buyer beware” regarding managed Medicare plans.

In case two, Humana denied IPR for another patient with a lower extremity amputation. During the peer-to-peer review, the reviewer stated that Humana directs physicians to deny all amputation cases, claiming IPR is only for “strength and conditioning,” which they deemed inappropriate. The patient was discharged to subacute rehabilitation but was readmitted weeks later for a contralateral amputation. Again, Humana denied IPR, with a second reviewer regurgitating the same reasoning about “strength and conditioning.”

Conclusions: Our IPR facility has tracked insurance authorizations for eight years. Since January 1, 2025, Humana has denied 100% of IPR requests for amputation patients according to our data. Other Medicare Advantage plans have also denied appropriate admissions, with three major insurers facing lawsuits for similar practices. Despite legal challenges, delays persist, and no clear enforcement mechanism ensures compliance with CMS guidelines.