Despite the Jimmo case’s confirmation that Medicare coverage of a stay in a skilled nursing facility (SNF) is appropriate to maintain a resident’s functional status, when the nursing or therapy services must be provided by a professional nurse or therapist, SNFs and managed care plans frequently continue to deny medically necessary coverage. Expedited appeals to keep Medicare-covered services in place require the resident/family to appeal to the Quality Improvement Organization (QIO) by noon the day after they receive a denial notice. Gathering medical support from the resident’s primary care physician or other relevant physician is often difficult under such strict time deadlines. While medical support is helpful and should be sought, families may be able to persuade the QIO to continue coverage, with careful documentation of what happened at the SNF.
The daughter of a resident recently sent the Center for Medicare Advocacy copies of the two letters she wrote to the QIO, both of which successfully persuaded Livanta to order the managed care plan to continue Medicare-covered care. The daughter described in detail how her mother had made clear progress during her limited stay; the absence of a “communicated care plan” or invitation to participate in a care planning meeting for her mother; the inadequate amount of therapy provided by the SNF; prejudgment by the managed care plan to limit coverage, based on the resident’s dementia; and Jimmo.
Ordering continued care, Livanta wrote, in the second successful appeal: “A review of the received medical records shows that the patient was admitted to the Skilled Nursing Facility (SNF) for rehabilitation following an acute care hospital stay for treatment of acute stroke. There is no sufficient documentation that the patient is ready for discharge from skilled services and the patient still requires daily skilled therapy services to maintain function or prevent decline. Termination of SNF services is not appropriate at this time.”
Copies of the redacted letters and Livanta decision are available.
- Information on Jimmo v. Sebelius and the Improvement Standard is available at: http://www.medicareadvocacy.org/medicare-info/improvement-standard/
- Resources for appealing Medicare Improvement Standard denials are available at: http://www.medicareadvocacy.org/take-action/self-help-packets-for-medicare-appeals/