HJBR Jan/Feb 2026

FIGHTING FOR CARE 10 JAN / FEB 2026 I  HEALTHCARE JOURNAL OF BATON ROUGE   require daily skilled nursing or skilled ther- apy in a SNF (skilled nursing facility) set- ting,” Humana claimed. “The services you require are called custodial care.” What is custodial care? “Custodial care helps you with daily needs,” Humana explained, “such as dressing, bathing, get- ting in and out of bed, going to the bath- room, and eating.” In other words, kiss all your dreams about going home to live an independent lifestyle goodbye. Custodial care helps people get by, but it is not a ther- apy that restores people to independent functioning. “Custodial care is not a covered benefit under Medicare or Humana,” they unsur- prisingly added. “You have completed your intensive course of care at the IRF.” Yvette said it was like Humana was will- fully ignoring how far Mom had come. They were essentially saying Momwould not get substantially better, and that she would spend the rest of her life with someone con- stantly taking care of her, including helping her go to the bathroom. All this, despite all of Mom’s progress, including, by that time, going to the bathroom with only moderate assistance. Fighting the System — Again and Again Under Medicare rules, our first level of appeal would be to Humana. Yvette filed an expedited appeal on Mom’s behalf. On Sept. 27, Humana replied to that appeal with another denial for SNF cover- age, but this time, they cited a completely contradictory rationale from their initial denial. “You are making progress with therapy,” they flatly admitted. Then, just days after claiming Mom had completed her course of intensive therapy, Humana completely contradicted itself, saying, “The informa- tion we received does not show that you have completed your full course of care in the IRF. Your records show that you con- tinue to require intensive therapy and will continue to benefit from rehabilitation ser- vices in order to return to the community/ home safely.” Humana’s reply then continued, “Your request does not meet Medicare guidelines because you are receiving adequate and necessary intensive rehabilitation in the Inpatient Rehabilitation Facility. All the ser- vices you need are offered at the IRF. Trans- fer to a SNF for inpatient rehab services is not medically necessary.” Humana told us we could discuss its decision with our pro- vider, and, the insurer added, “they [Mom’s provider] can send more records.” When Yvette later spoke to a Humana representative on the phone, she eventu- ally got the representative to admit that none of Humana’s explanations made any sense. That person also admitted that they couldn’t do anything about it. A couple of months after Mom left the IRF, we learned why (more on that later). Yvette told us that Humana invitedMom’s IRF to engage in something called a peer- to-peer review, a conversation between a Humana representative and Mom’s doctor about the denial. The IRF declined doing a review because IRF staff have learned the reviews are a waste of time. When I talked to my cousin Donna, who runs two medical facilities in Terrebonne Parish, about the peer-to-peer review pol- icy at Mom’s IRF, she agreed with it and said she has the same policy at both facili- ties she runs. “They’re staged,” she said of the reviews, describing them as a veneer designed to create the illusion that compa- nies like Humana care about anything but the bottom line. What we later learned about the whole denial-and-review process is that they’re controlled by artificial intelligence. About two and a half months after Mom’s stay at the IRF, a class-action lawsuit was filed against Humana for using unregulated arti- ficial intelligence to determine who gets post-acute care after a hospitalization, and when it’s cut off. “Humana intentionally limits its employees’ discretion to deviate” from the model, the suit states. “Employees who deviate from the nH Predict AI Model projections are disciplined and terminated, to be aware.” Brian would become one of count- less medical professionals of all stripes to express their open disdain for Medicare Advantage plans, with Humana being the consensus villain. “They’re the worst,” we heard so many times. Many of the medi- cal professionals we encountered offered unsolicited horror stories they were forced to be a part of. That’s why we were so thankful to learn that Humana approved Mom’s transfer to the IRF. As Mom settled into her new digs that Thursday evening, Edie and I got to know our angel of a social worker, Yvette. She’d later tell us how the folks running the IRF had been considering no longer tak- ing Humana patients because of the grow- ing number of denials the insurer had been issuing for subsequent transfers to other, less intensive, post-acute care facilities, like skilled nursing facilities (SNFs). Since the administrators of the IRF are not monsters, Yvette explained, they don’t just throw peo- ple out on the street upon such denials, like many other places do. Mom’s recovery plan called for two to three weeks at the IRF, then a longer stint at a SNF, followed by her return home, where she’d receive home health and outpatient therapy. Three weeks after arriving at the IRF, Mom had made tremendous gains in phys- ical, occupational, and speech therapy, to the point that she was introducing her therapists to new words, like “antiquated.” (Mom used it to describe the IRF’s paper- based system.) By this point, Mom had ticked every box to qualify for SNF cover- age and a transfer to one of the best-rated SNFs in town. A visibly upset Yvette met us in Mom’s room on Friday, Sept. 22, to tell us Humana had denied SNF coverage. She had concur- rently applied for skilled nursing for another Humana patient with a similar profile and recovery trajectory as Mom. The other patient was approved. So why was Mom denied? “Your record does not show that you