Successful appeal for PT paid for by Medicare?

[Anonymous]

My father suffered a stroke and was discharged to a sub-acute rehab facility. He received PT and OT for less than 2 weeks before Medicare would not pay anymore. My understanding is they would pay 100 days. We appealed it and they said he was better and didn’t need it. I don’t understand it because he is still in a wheelchair and unable to walk or stand. Clearly, he stills needs PT. Anyone successfully appeal? I wonder if I get his doctor to request PT, they would pay. Or if Medicaid will pay (he qualified for Medicaid).

[Anonymous]

Medicaid and/or Medicare should pay. His doctor should put in a new referral.

[Anonymous]

You’ve got several options. Here you can do a member requested appeal, you can ask for a peer to peer call when your doctor will speak to one of their doctors at the insurance company. This is a critical statement that you need to say, over and over again: you want a specialty matched physician to review your father’s case. So in this case you’re looking at internal medicine with a specialty in geriatrics or better yet physical medicine and rehab. Do not accept an insurance denial from a board certified gynecologist or psychiatrist.

[Anonymous]

With my mom, her PCP just kept writing more Rxs for it, but we had to take her. For the people who came to the house, they had to keep saying she qualified in addition to the PCP. They were pretty worthless.

Something definitely seems off with how yours if going. Two weeks isn't enough. It's usually several weeks at a time before you need a new Rx from the doctor.

[Anonymous]

I think if there is zero progress then they don’t pay anymore. Has he gotten better at all after the stroke? Did he progress at all with PT?

[Anonymous]

I forgot to add. If he isn’t willing to do PT then they won’t pay. This is what happened to my FIL. He didn’t really want to do PT after a stroke so didn’t make progress so then Medicare no longer paid.

[Anonymous]

It’s not an automatic 100 days. It’s subject to utilization review. There has to be progress and there are preset conditions for discharge.

Medicaid might pay if he qualifies for long term care.

The discharge planner and/or social worker should be able to help.

[Anonymous]

Perhaps they felt he plateaued?

[Anonymous]

Can you get him to outpatient? Then any order from an MD will work.

[Anonymous]

I'm familiar with commercial insurance and not Medicare, but these are ideas for how I'd approach it if it were my parents. Also I'm unclear form your post if it's staying in the facility getting rejected or PT and OT itself. Could there be a difference related to that? I would think there would come a time when he'd be well enough to go home but still need services at be home or outpatient.

Does he have traditional Medicare or a Medicare Advantage plan? Do you know the exact wording and code for the denial other than he's better? I would ask Medicare/the MA plan these things if they are not obvious. Then ask the facility what they think the submitted in support of medical necessity. Could be a lost paperwork issue on either side.

[Anonymous]

Does he have Medicare or Medicare Advantage (which should really be called Medicare Disadvantage)? If the latter, they try to drop all services ASAP, and there's nothing you can do about it; the insurance company's decision override Medicare.