Reply to Medicare appeal question - discharge from subacute rehab

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[quote=Anonymous][quote=Anonymous][quote=Anonymous]To qualify he needs to be able to participate in a certain number of hours a day. Is he meeting criteria?  Also is he progressing from an objective standpoint t?

If the answer is no to either question, then you don’t have a leg to stand on. But residents can move between levels of care. The good news is they are keeping him which makes that easier.

The bigger issue to me would be what level of therapy will he receive at LTC.  There should be some and it might be more appropriate given that he doesn’t seem to be able to participate.

Last things. You only have a limited number of rehab days. Is this really how you want to use them?  And if you lose the appeal, how will he pay because the facility will collect their money. [/quote]

This is incorrect...

On January 24, 2013, the U. S. District Court for the District of Vermont approved a settlement 
agreement in the case of Jimmo v. Sebelius, in which the plaintiffs alleged that Medicare contractors 
were inappropriately applying an “Improvement Standard” in making claims determinations for 
Medicare coverage involving skilled care (e.g., the skilled nursing facility (SNF), home health 
(HH), and outpatient therapy (OPT) benefits).

For example, in the regulations at 42 
CFR 409.32(c), the level of care criteria for SNF coverage specify that 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.[/quote]

Apologies to OP. The standard is improvement or prevention of deterioration. I was writing quickly. The remaining things I said stand - ability to participate and max days available. 
[/quote]

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