Appealing Medicare Denials Caused by “Plateauing”

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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