In Home Health, LLC v. Robert F. Kennedy, Jr., No. 25-3542 (6th Cir. July 27, 2026). Published for Binding Precedent per Sixth Circuit I.O.P. 32.1(b).

I. Introduction

On July 27, 2026, the United States Court of Appeals for the Sixth Circuit issued a groundbreaking decision in In Home Health, LLC v. Robert F. Kennedy, Jr., in his official capacity as Secretary of the United States Department of Health and Human Services, No. 25-3542. This decision marks the first time a federal appellate court has addressed hospice reimbursement under the Medicare Act, establishing a provider-friendly standard for the application of Medicare’s “safe harbor” provision under 42 U.S.C. § 1395pp.

The Sixth Circuit’s ruling vacated the lower court’s decision and adopted a standard that protects healthcare providers who reasonably—albeit incorrectly—interpret Medicare notices and standards as covering a patient’s claims. The decision has profound implications not only for hospice providers facing Medicare audits and claim denials, but for all Medicare participants who rely on the limitation of liability provision as a shield against retroactive payment demands.

This article examines the factual background, the court’s reasoning, and the far-reaching significance of this precedent-setting opinion for the healthcare industry.

II. Background of the Case

A. The Parties and the Dispute

In Home Health, LLC is a Medicare-certified provider of hospice services. Under the Medicare hospice benefit, providers furnish palliative care to patients who are certified as terminally ill with a life expectancy of six months or less if the disease runs its normal course. Eligibility determinations are inherently clinical judgments, grounded in the treating physician’s and the hospice medical director’s assessment of the patient’s prognosis.

In 2020, a Medicare Administrative Contractor (MAC) denied more than 250 claims of coverage for nine hospice patients served by In Home Health. The denials would have forced the company to repay more than $1 million in Medicare payments it had already received for services rendered. In Home Health had based its coverage decisions on the clinical opinion of its medical director, who determined that the patients in question were terminally ill and had a life expectancy of less than six months.

B. Administrative Proceedings

The case proceeded through the Medicare administrative appeals process, where an Administrative Law Judge (ALJ) issued a partially favorable decision. The ALJ determined that Medicare covered 52 of the disputed claims that the contractors had deemed uncovered. However, the ALJ upheld the denial of 104 claims relating to four patients.

Critically, the ALJ’s analysis of the safe harbor provision under 42 U.S.C. § 1395pp turned on whether In Home Health had “knowledge of” the relevant Medicare notice on hospice standards—specifically, Hospice – Determining Terminal Status LCD 33393, which contains criteria to determine a patient’s terminal prognosis. The ALJ concluded that because In Home Health was aware of the LCD, it could not benefit from the safe harbor, and therefore was liable to repay the denied claims.

C. District Court Proceedings

The United States District Court for the Northern District of Ohio partially upheld the ALJ’s denials. In Home Health then appealed to the Sixth Circuit Court of Appeals. Good for them for continuing to appeal!!

D. The Statutory Framework

The central statutory provision at issue is the Medicare “safe harbor” or “limitation of liability” provision, codified at 42 U.S.C. § 1395pp. This provision protects providers from liability for noncovered services if the provider did not know and “could not reasonably have been expected to know” that Medicare would not cover a particular claim. As applied to hospice, the statute provides that a provider cannot be held liable if it could not reasonably have been expected to know that “an individual is not terminally ill.” 42 U.S.C. § 1395pp(a)(2), (g).

The LCD at issue—Hospice – Determining Terminal Status LCD 33393—sets forth criteria that must be present in clinical documentation to support a terminal prognosis. Hospices found in violation of the limitation of liability provision are required to return Medicare payments for the denied claims.

III. The Sixth Circuit’s Ruling

A. Vacating the Lower Court Decision

The Sixth Circuit vacated the district court’s decision, finding that the ALJ had incorrectly applied the safe harbor provision. The court identified a fundamental error in the analytical framework employed by the ALJ: rather than merely asking whether In Home Health knew about the operative Medicare notice on hospice standards, the ALJ should have asked whether the provider adopted a reasonable interpretation of the operative Medicare notice as applied to the relevant claims.

B. The Proper Standard

The court articulated the following standard in clear terms:

“If the provider is on clear notice that Medicare would not cover the claim, it does not fall within the safe harbor… But if a provider reasonably—albeit incorrectly—interpreted the Medicare notices and standards as covering a patient’s claims, then the safe harbor saves them from liability.”

This articulation draws a critical distinction. Under the ALJ’s approach, mere awareness of an LCD would disqualify a provider from safe harbor protection—essentially imposing strict liability on any provider that knew a coverage standard existed. The Sixth Circuit rejected this interpretation, holding instead that the proper inquiry is whether the provider’s application of the standard to particular patients was reasonable, even if ultimately incorrect.

C. Remand

The Sixth Circuit vacated the district court’s decision and remanded the case with instructions to return it to the ALJ. The ALJ must now apply the safe harbor under the proper statutory standard in the first instance, evaluating whether In Home Health’s interpretation of the LCD criteria, as applied to the specific patients at issue, was reasonable—not merely whether the provider was aware that the LCD existed.

IV. Legal Significance and Importance of the Decision

A. First Appellate Decision on Hospice Reimbursement

The In Home Health decision represents the first time any federal court of appeals in the United States has addressed hospice reimbursement under the Medicare Act.

The precedential weight of this decision cannot be overstated. While binding only in the four states of the Sixth Circuit—Kentucky, Michigan, Ohio, and Tennessee—it will serve as highly persuasive authority in every other federal circuit and in administrative proceedings nationwide.

B. Establishment of a Provider-Friendly Standard

The ruling establishes a critical principle: a provider’s mere awareness of Local Coverage Determinations does not, standing alone, establish knowledge of noncoverage sufficient to defeat safe harbor protection. Going forward, providers will receive Medicare reimbursement so long as they reasonably interpret regulatory requirements as applied to particular patients. This is a substantial departure from the restrictive approach many ALJs had previously applied, under which knowledge of an LCD’s existence was essentially treated as constructive knowledge that any claim not perfectly aligned with every LCD criterion would be denied.

C. Recognition of Clinical Uncertainty in Prognostication

Perhaps most significantly for the hospice industry, the Sixth Circuit recognized the inherently uncertain nature of terminal prognostication. The court acknowledged the “grey area” that characterizes end-of-life clinical judgments. This recognition reflects a medical reality that the administrative process had often ignored: predicting the trajectory of terminal illness is not an exact science.

Indeed, approximately 22% of hospice patients are eventually discharged alive—a statistic that underscores how often a terminal prognosis may extend beyond the expected timeframe without indicating error or fraud on the provider’s part.

D. Broader Applicability Beyond Hospice

While this case arose in the hospice context, its implications extend far beyond that sector. The safe harbor provision at 42 U.S.C. § 1395pp applies to all Medicare participants. The Sixth Circuit’s interpretation of the “could not reasonably have been expected to know” standard will apply wherever a Medicare provider faces recoupment demands and invokes the limitation of liability defense. Hospitals, skilled nursing facilities, home health agencies, durable medical equipment suppliers, and other Medicare providers may all benefit from this provider-friendly standard.

V. Implications for Hospice Providers and the Healthcare Industry

A. Impact on Pending Litigation

The decision arrives at a moment when hospice providers across the country face aggressive Medicare audit activity. I also represent hospice providers in dozens of similar matters pending in administrative proceedings and district courts nationwide. The Sixth Circuit’s provider-friendly precedent may significantly increase the likelihood of success in those and other pending and future cases.

Recent federal court decisions—including this one—signal that the “scales” may be tilting in favor of providers. Providers need this favor. The provider appeal process is so esoteric and frustrating. This is a good win.

B. Shifting the Analytical Framework

For hospice providers and their counsel, the decision fundamentally changes the terrain of Medicare reimbursement disputes. Under the prior regime applied by many ALJs, the analytical framework was straightforward and unforgiving: if the provider knew the LCD existed, the safe harbor was unavailable. Under the Sixth Circuit’s standard, the inquiry is more nuanced and fact-intensive: did the provider reasonably interpret the applicable standards as supporting coverage for this particular patient?

This shift places renewed emphasis on the quality of clinical documentation. Providers whose medical directors apply LCD criteria in good faith, document their reasoning, and reach clinically supportable conclusions will be in a strong position to invoke the safe harbor even if a retrospective audit reaches a different clinical judgment.

C. Jurisdictional Considerations

The ruling is binding precedent in the four states covered by the Sixth Circuit: Kentucky, Michigan, Ohio, and Tennessee. However, as the first appellate decision on this issue, it carries substantial persuasive weight in other jurisdictions. Federal district courts and ALJs outside the Sixth Circuit may look to this decision for guidance, particularly given the absence of contrary appellate authority.

Providers operating in multiple states should assess the potential applicability of this standard in their respective jurisdictions and consider whether filing venue may be strategically relevant in future disputes.

D. Potential for Further Proceedings

The government retains the option of seeking review by the United States Supreme Court through a petition for writ of certiorari. Whether the government chooses to do so will depend on multiple factors, including the strength of the government’s position, the existence (or emergence) of a circuit split, and policy considerations within the Department of Health and Human Services.

Industry advocates have expressed hope that the Centers for Medicare and Medicaid Services (CMS) may adopt the safe harbor standard more broadly for hospices at the national level, potentially through rulemaking or sub-regulatory guidance. Such action would provide uniform national protection for hospice providers and reduce the current patchwork of inconsistent administrative decisions.

E. Practical Guidance for Providers

In light of this decision, hospice providers and other Medicare participants should consider the following steps:

• Document clinical reasoning thoroughly. Ensure that medical directors and certifying physicians clearly articulate the clinical basis for each terminal prognosis determination, referencing applicable LCD criteria and explaining how clinical findings support the prognosis.
• Demonstrate good-faith interpretation of standards. Maintain policies and training programs that reflect a reasonable, good-faith effort to comply with LCD requirements, recognizing that compliance need not be perfect to warrant safe harbor protection.
• Reassess pending disputes. Providers with claims currently in administrative appeal or federal court should evaluate how this decision may strengthen their safe harbor arguments, particularly if denials were based on a constructive knowledge theory.
• Consider jurisdictional strategy. For providers with operations in the Sixth Circuit or flexibility in filing venue, this binding precedent should inform litigation strategy.
• Monitor further developments. Watch for potential government appeal, CMS guidance, or sister-circuit decisions that may affect the national landscape.

VI. Conclusion

The Sixth Circuit’s decision in In Home Health, LLC v. Robert F. Kennedy, Jr. represents a watershed moment in Medicare hospice reimbursement law. By establishing that the safe harbor provision protects providers who reasonably interpret Medicare standards—even when their clinical judgments are later second-guessed by auditors—the court has provided meaningful protection against the retroactive recoupment demands that have plagued the hospice industry.

The decision recognizes a fundamental truth about hospice care: prognostication is an inherently uncertain clinical exercise, and the Medicare program itself acknowledges this uncertainty in its own standards. Penalizing providers who make good-faith clinical judgments within the bounds of reasonable interpretation would chill access to hospice services and ultimately harm the terminally ill patients who need them most.

As the first appellate court to address these issues, the Sixth Circuit has set a standard that will resonate throughout the healthcare industry. Whether through adoption by other circuits, application in pending administrative proceedings, or potential CMS action at the national level, the principles articulated in this decision are likely to shape Medicare reimbursement law for years to come.

Healthcare providers—particularly those in the hospice space—should take note of this decision and work with experienced counsel to ensure their clinical documentation and compliance programs position them to benefit from the safe harbor protection the Sixth Circuit has now clearly defined.

Kudos to In Home Health for fighting this fight all the way to the 6th Circuit!!! A lot of providers would have given up. This case showcases what perseverance can do!