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Appealing Medicare Denials Caused by “Plateauing”

June 17, 2010

Under Medicare law, a person is entitled to continue to receive physical therapy or other medical rehabilitative care even after reaching a so-called “plateau.”  Many rehabilitation centers and nursing homes refuse to continue to give physical therapy or other medical rehabilitative care unless the patient shows the ability to continue to improve, but what is routinely going on is a denial of the patient’s rights under Medicare law.  Medicare regulations at 42 CFR 409.32(c) specifically state:  “The restoration potential of a patient is not the deciding factor in determining whether skilled services are needed.  Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities.”  http://edocket.access.gpo.gov/cfr_2002/octqtr/pdf/42cfr409.33.pdf

The need for continued therapy is especially important for those persons whose quality of life would decline without it, especially those with degenerative diseases.  See How the “Improvement Standard” Improperly Denies Coverage to Medicare Patients with Chronic Conditions

Fortunately, the Center for Medicare Advocacy, Inc., of Willimantic, Connecticut, has initiated a national campaign to change this mentality that is so engrained in the health care system.  http://www.medicareadvocacy.org/Projects/Improvement/ImprovementMain.htm

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One Comment leave one →
  1. Suzanne permalink
    January 27, 2011 8:11 pm

    Brian, I operate a contract rehab company where we only provide PT, OT, and/or ST, in SNFs. I will frequently hear therapists comment that Med B (LTC) census is low because it will be difficult to show progress and Medicare will deny payment. I am an OTR and a strong patient advocate. i know there is always something I can do to facilitate increased function and quality of life with just about any patient/resident of a SNF. Could you provide me with any additional information related to the comment above? For example, for someone with RA or another progressively debilitating disease, it is accepetable by Medicare standards that therapy continue (Not as a maintenance program, but more of incremental gains)? Any information or guidance will be greatly appreciated.

    thank you
    suzanne

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