For years, some people on Medicare had difficulty getting insurance coverage approved for physical therapy, occupational therapy and other treatments. The prevailing approach was that if the therapy was not helping to improve a patient’s condition, then it was not eligible for coverage.
“They’d get denied because they weren’t improving, or because they had plateaued,” said Judith Stein, executive director of the Center for Medicare Advocacy, a nonprofit consumer group. The situation was especially difficult, she said, for patients with chronic or degenerative conditions, like Parkinson’s disease or multiple sclerosis.
That is changing, as a result of a 2013 settlement of a lawsuit that the center and others brought against the secretary of the Health and Human Services Department, the parent agency of the Centers for Medicare and Medicaid Services, which oversees Medicare. The suit claimed that Medicare billing contractors were inappropriately denying coverage for “skilled” care by applying an “improvement” standard as a rule of thumb.
Because of the settlement, the agency updated its policy manuals last year. The revisions make clear that if treatment is needed to prevent or slow further deterioration in a patient’s condition, “coverage cannot be denied based on the absence of potential for improvement or restoration.” The update applies to therapy provided in nursing homes, in outpatient clinics and at home. (The agency maintains that the revision was not a change, but was made to “clarify” what had been existing Medicare policy.)
Navigating Medicare Policy on Physical Therapy and Other Services - NYTimes.com
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