Home modification benefit denied as “home improvement”: how to appeal or re-request

Introduction

If your plan denied a ramp, grab bars, doorway widening, or other home changes as “home improvement,” you are not alone. These denials are common because insurers often separate medical benefits from property upgrades, even when the change is needed for safety and daily function.

The good news is that many denials can be appealed or re-submitted successfully when you (1) confirm the right coverage pathway and (2) present the request in the language your plan uses for health and safety needs.

Key points to know

• A “home improvement” denial usually means the plan thinks the request is not a covered benefit category, not medically necessary, or not submitted through the right program.
• Strong appeals focus on safety and functional independence, supported by clinician documentation and (when possible) an occupational therapy home safety assessment.
• Some coverage types rarely pay for structural changes, while others may cover them under specific benefits, such as Medicaid HCBS “environmental modifications” or certain Medicare Advantage supplemental benefits.

Why insurers label home modifications as “home improvement”

Plans often deny home modifications for one or more of these reasons:

• Benefit exclusion: The plan does not cover structural home changes under standard medical benefits.
• Not framed as a health and safety need: The request is described as a general upgrade rather than a functional accommodation tied to a medical condition.
• Missing required documentation: No clinician order, therapy evaluation, or evidence of functional limitation.
• Wrong pathway: The request may belong under a different program (for example, Medicaid HCBS, a Medicare Advantage supplemental benefit, or a VA grant) rather than standard claims processing.

Start by confirming what kind of coverage is involved

Before you write an appeal, identify what is actually denying you. The steps and success rate can differ a lot.

If you have private insurance

Most non-grandfathered private plans must offer an internal appeal and, in many situations, an independent external review.
Your denial letter should say whether it is a claim denial, a coverage denial, or a prior authorization denial.

If you have Medicare Advantage

Medicare Advantage plans must follow a specific coverage decision and appeals structure, and you can request a standard or expedited reconsideration depending on urgency.
Some Medicare Advantage plans may offer supplemental benefits that can include structural home modifications for qualifying members, but the plan’s rules still control what is approved.

If you have Medicaid HCBS or long-term services and supports

Many Medicaid home modification approvals flow through HCBS programs and require the modification to be certified as necessary and documented in a person-centered plan.
A denial may reflect missing plan-of-care documentation or a mismatch between what was requested and what the waiver service definition allows.

If you are a Veteran

VA programs may help pay for home changes like ramps and widened doorways through disability housing grants, and some VA locations administer HISA benefits for medically necessary home alterations.

Quick steps to take right after a denial

Take these steps in order, even if you plan to re-request instead of appeal:

• Read the denial letter closely. Identify the stated reason: “not covered,” “not medically necessary,” “home improvement,” “insufficient documentation,” or “out of network.”
• Ask for the exact policy basis. Request the benefit language, clinical criteria, or coverage guideline that was used.
• Collect your records. Include the denial letter, the original request, clinician notes, therapy notes, and any prior authorization communications.
• Document the home hazard. Photos, short written descriptions, and examples of near-falls or barriers to bathing, toileting, transfers, or exiting the home can help.
• Start a simple timeline. Track dates, names, call reference numbers, and what you were told. This is useful for both internal appeal and external review.

Build a strong “medical necessity” case

Even when a request involves your home, your appeal should center on health, safety, and day-to-day function.

Document functional limitations and safety risks

Write down specific examples of what you cannot do safely right now, such as:

• Difficulty stepping over a tub edge or standing in the shower
• Inability to climb stairs to reach a bedroom or bathroom
• Unsafe transfers from wheelchair to toilet
• Falls or near-falls related to lighting, thresholds, loose rugs, or lack of handholds

National fall prevention guidance emphasizes identifying hazards room by room and making changes to reduce fall risk.

Request a home safety assessment by occupational therapy or physical therapy

A home assessment can translate your daily challenges into a clinical summary and recommendations. The National Institute on Aging notes that clinicians such as occupational therapists can assess home safety and advise changes to lower fall risk.

Research reviews also describe home-hazard assessment and modification as a fall-prevention strategy and note occupational therapy as a common pathway for delivering home hazard assessment and modification.

Align your language with payer definitions

When you write your appeal or re-request, use the terms your coverage type recognizes:

• For Medicaid HCBS, “environmental modifications” are described as adaptations necessary for health and safety or to enable greater independence, and they must be documented and tied to the person-centered plan.
• For certain Medicare Advantage supplemental benefits, CMS has described “structural home modifications” as permitted examples for eligible chronically ill enrollees, such as permanent mobility ramps or widening doorways, when there is a reasonable expectation of improving or maintaining health or overall function.

How to write an appeal that directly addresses “home improvement”

Think of your appeal as a short, organized packet that makes it easy to overturn the denial.

What to include in your appeal packet

• Your denial letter and any reference number
• A one-page cover letter stating what you are requesting and why the denial should be overturned
• A clinician letter that connects the diagnosis to functional limitations and safety risk
• OT or PT home safety assessment and recommendations, if available
• Photos of the specific hazard and where the change would be installed
• Itemized contractor estimate or supplier quote
• Any plan language that supports coverage under the correct benefit category (if applicable)

For private plans, federal resources emphasize your right to understand why you were denied and to submit additional information such as a doctor’s letter.

How to frame your request

Use short, direct statements that shift the request from “upgrade” to “safety accommodation”:

• State the purpose in functional terms: “to transfer safely,” “to bathe safely,” “to exit the home for medical care,” “to reduce fall risk.”
• Tie the request to clinical recommendations: “recommended after home safety assessment” or “recommended to reduce hazards identified by OT.”
• Describe the consequence of denial: falls risk, inability to toilet safely, inability to access medical appointments, or caregiver injury risk.
• If your coverage type supports it, label it correctly: “environmental modification” for Medicaid HCBS or “structural home modification” for certain Medicare Advantage supplemental benefits.

When to request an expedited decision

If delaying the decision could seriously jeopardize health or function, ask about a fast or expedited appeal option where available. Medicare Advantage materials describe expedited timelines when waiting could cause serious harm.

When it may be better to re-request instead of appeal

Sometimes the fastest path is a corrected re-request that uses the right benefit category and documentation.

Re-request through a covered pathway when one exists

Depending on your plan, you may have a better chance if you submit the request as:

• A benefit the plan explicitly offers for home safety or functional support
• A Medicaid HCBS environmental modification listed in the person-centered plan
• A Medicare Advantage supplemental benefit, if your plan offers it and you meet eligibility criteria

If you have Medicaid HCBS

Ask your care manager or waiver support team these specific questions:

• What is the waiver service name for home modifications in your state?
• What documentation is required to certify the modification as necessary?
• Does the modification need to be added to your person-centered plan before approval?

If you have Medicare Advantage and a chronic condition

Ask the plan whether you have access to any supplemental benefits that can cover home safety changes, and what criteria apply. CMS guidance has included structural home modifications as an example of permitted supplemental benefits for certain chronically ill enrollees when the expectation of improved or maintained function is met.

Escalation options if you are denied again

Private insurance: internal appeal then external review

For many plans, you have the right to an internal appeal, and if the plan upholds its denial, you may qualify for an independent external review.
Consumer-facing guidance also emphasizes keeping your appeal in writing and following the denial letter’s instructions.

Medicare: follow the coverage-specific appeals track

Medicare describes that the appeals process varies by coverage type and generally includes multiple levels.
If you are in a Medicare health plan, follow the plan’s denial notice instructions for how to request reconsideration.

Keep your documentation organized

No matter the payer, strong records help:

• Keep every letter, fax confirmation, and portal screenshot
• Write down the date you submitted materials and how
• Ask for written confirmation that your packet is complete

Other ways to get help paying for home modifications when insurance won’t

If your plan truly excludes the benefit, you still have options that may be worth exploring:

• Medicaid HCBS waivers: Many states offer services that help people receive care at home rather than in institutions, and environmental modifications may be part of that structure.
• VA housing grants and HISA benefits: VA programs may fund home changes like ramps and doorway widening for eligible Veterans.
• Local aging and disability resources: The Eldercare Locator is a public service that connects older adults and families to services in their community.

Home hazard assessment and modification is also recognized in fall prevention evidence and practice resources, which can strengthen your case when you seek funding from any source.

Understood Care resources that may help

If you want help organizing documents, understanding your denial, or preparing to re-request:

• Mobility Equipment Access and Home Safety: https://understoodcare.com/care-types/mobility-equipment
• Breaking Down Medical Bills: https://understoodcare.com/articles/breaking-down-medical-bills
• Financial Help: https://understoodcare.com/articles/financial-help

Conclusion

A “home improvement” denial can feel final, but it often reflects a classification problem, missing documentation, or the wrong coverage pathway. If you reframe the request around health and safety, add a clinician or OT assessment when possible, and submit it through the right benefit category, you give yourself the best chance to win an appeal or get a clean approval on a re-request.

FAQ

• What does it mean when a home modification is denied as “home improvement”? It usually means the plan sees it as a property upgrade, not a covered medical benefit, or it was submitted under the wrong category.
• How do I appeal a denied home modification request with private insurance? File an internal appeal on time, include your denial letter, and submit added documentation such as a clinician letter and safety evidence.
• Can Medicare Advantage cover home modifications like ramps or widened doorways? Some plans may offer supplemental benefits that can include structural home modifications for eligible members under specific criteria.
• Does Original Medicare pay for home modifications? Medicare advocacy guidance notes that Medicare does not cover structural home modifications under the DME benefit.
• What documentation makes a home modification appeal stronger? A clinician letter tying the request to function and safety, plus an OT home hazard assessment and clear photos or descriptions of the hazard.
• How do Medicaid HCBS environmental modifications work? They are adaptations necessary for health and safety or greater independence and generally must be certified as necessary and included in a person-centered plan.
• Where can I find local help paying for home modifications if insurance denies them? The Eldercare Locator can connect you to community services for older adults and families.
• Are home hazard assessments and modifications actually linked to fall prevention? Evidence reviews describe home hazard assessment and modification as an intervention pathway, often delivered by occupational therapy, and public health resources include home modification interventions.

References

• National Institute on Aging. Preventing Falls at Home: Room by Room. https://www.nia.nih.gov/health/falls-and-falls-prevention/preventing-falls-home-room-room
• Centers for Disease Control and Prevention. Check for Safety: A Home Fall Prevention Checklist for Older Adults (PDF). https://www.cdc.gov/steadi/pdf/STEADI-Brochure-CheckForSafety-508.pdf
• CDC. Falls Compendium: Older Adult Fall Prevention. https://www.cdc.gov/falls/interventions/falls-compendium.html
• Systematic Reviews (peer-reviewed). Falls prevention interventions for community-dwelling older adults: systematic review and meta-analysis. https://link.springer.com/10.1186/s13643-024-02681-3
• HealthCare.gov. Internal appeals. https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/
• CMS (CCIIO). Has Your Health Insurer Denied Payment for a Medical Service? You Have a Right to Appeal. https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/appeals06152012a
• National Association of Insurance Commissioners (NAIC). Health Care Bills: How to Appeal a Denied Claim (PDF). https://content.naic.org/sites/default/files/inline-files/how-to-appeal-a-denied-claim.pdf
• Medicare.gov. Filing an appeal. https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals
• Medicare.gov. Appeals in Medicare health plans. https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/medicare-health-plans
• CMS. Reconsideration by the Medicare Advantage (Part C) Health Plan. https://www.cms.gov/medicare/appeals-grievances/managed-care/reconsideration-advantage-health-plan-part-c
• CMS. Supplemental Benefits for Chronically Ill (HPMS memo, PDF). https://www.cms.gov/medicare/health-plans/healthplansgeninfo/downloads/supplemental_benefits_chronically_ill_hpms_042419.pdf
• CMS. HCBS Common Errors for DME, Supplies, Devices, and Environmental Modifications (PDF). https://www.cms.gov/files/document/hcbs-common-errors-dme-factsheet-102815pdf
• CMS. National Overview of 1915(c) HCBS Waivers. https://www.cms.gov/outreach-and-education/american-indian-alaska-native/aian/ltss-ta-center/info/national-overview-1915-c-waivers
• Veterans Affairs. Disability housing grants for Veterans. https://www.va.gov/housing-assistance/disability-housing-grants/
• Veterans Affairs. Home Improvements/Structural Alterations (HISA). https://www.va.gov/fayetteville-coastal-health-care/programs/home-improvementsstructural-alterations-hisa/
• Administration for Community Living. Eldercare Locator. https://eldercare.acl.gov/home
• Medicare Interactive. Home modifications to continue living at home. https://www.medicareinteractive.org/understanding-medicare/medicare-covered-services/limited-medicare-coverage-long-term-care-services/home-modifications-to-continue-living-at-home

This information is for general education and does not replace medical advice from your own clinicians or care team. If you are considering PACE or have questions about PACE program food benefits, talk directly with your local PACE organization or a trusted advocate.