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The Center for Medicare Advocacy is concerned that Medicare beneficiaries are being denied Medicare coverage for skilled services that are specifically listed as covered by Medicare in federal regulations. Medicare covers various skilled therapies (physical, speech–language pathology and occupational) and skilled nursing services, including observation and assessment, management and evaluation of a care plan, or patient education.[1] Medicare regulations also list nine specific services that are defined as skilled and covered by Medicare. [2]

The nine services, which apply to both skilled nursing facilities and to home health care, are:

  1. Intravenous or intramuscular injections and intravenous feeding;
  2. Enteral feeding (i.e., “tube feedings”) that comprises at least 26 per cent of daily calorie requirements and provides at least 501 milliliters of fluid per day;
  3. Nasopharyngeal and tracheostomy aspiration;
  4. Insertion and sterile irrigation and replacement of suprapubic catheters;
  5. Application of dressings involving prescription medications and aseptic techniques;
  6. Treatment of extensive decubitus ulcers or other widespread skin disorder;
  7. Heat treatments which have been specifically ordered by a physician as part of active treatment and which require observation by nurses to adequately evaluate the patient's progress;
  8. Initial phases of a regimen involving administration of medical gases; or
  9. Rehabilitation nursing procedures, including the related teaching and adaptive aspects of nursing that are part of active treatment, e.g., the institution and supervision of bowel and bladder training programs.[3]

The Center recently received a denial of Medicare coverage for skilled nursing services for intramuscular injections of vitamin B-12 for an approved diagnosis in a home health case. This patient was homebound and met all the criteria for Medicare coverage of home care. So far, at each level of appeal, the Medicare Contractor or judge has inappropriately denied Medicare coverage. The latest reason for denial is that the “Vitamin B-12 injection products are often purchased without a prescription and self-injected by individuals without medical training.” This reason for denying a skilled nursing service is improper, and we will pursue the case.

Most often the nine skilled services are automatically covered by Medicare, however, denials seem to be occurring more frequently for services that Medicare recognizes as “per se” skilled. We are seeing denials most often for tube feedings, wound care and intramuscular injections, but any of the nine per se skilled services may be improperly denied.

We encourage people to appeal improper denials of skilled care, particularly of per se skilled care.  We want to monitor instances of these denials, whether in traditional Medicare or with Medicare Advantage companies. Please let us know by emailing

August, 2015 – M. Murphy

[1] 42 CFR 409.33(a)
[2] 42 CFR 409.33(b)
[3] See also CMS Medicare Benefit Policy Manual, Pub. 100-02, Ch. 8, Sec. 30.3 and Ch. 7, Sec. 40.1 et seq.

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