Jimmo v. Sebelius, No. 11-cv-17 (D. VT), is a nationwide class-action lawsuit brought on behalf of Medicare beneficiaries who received care in skilled nursing facilities, home health care, and outpatient therapy and who were denied Medicare coverage on the basis that they were not improving or did not demonstrate a potential for improvement (known as the “Improvement Standard). On January 24, 2013, the U.S. District Court for the District of Vermont approved a Settlement in Jimmo between attorneys for the Jimmo plaintiffs (the Center for Medicare Advocacy and Vermont Legal Aid) and the Centers for Medicare & Medicaid Services (CMS).
When Should Medicare Coverage be Available for Outpatient Therapy?
Physical, speech-language pathology, and occupational therapies can be covered by Medicare Part B if they meet the following criteria:
- The patient’s physician or authorized health care provider orders and periodically reviews the patient’s therapy regimen.
- The therapy is “medically necessary.” This means that the therapy provided is considered a specific and effective treatment for the patient’s condition under accepted standards of medical practice.
- The therapy required can be safely and effectively performed only by, or under the supervision of, a qualified therapist because of the complexity of the therapy or medical condition of the patient.
Other Important Points:
- Too often, Medicare denials are based on a belief that the patient’s medical condition will not significantly improve. However, “restoration potential” is notrequired under the law. Therapy to maintain an individual’s condition or slow deterioration can be coveredif a skilled professional is necessary to provide or supervise the care.
- Therapy that can ordinarily be performed by a nonskilled person can be covered by Medicare if the patient’s condition is so medically complex that it requires a skilled therapist to perform or supervise the care.
- There is no longer a cap on the amount of therapy Medicare will cover each year. The definite limit on therapy was repealed in 2018. Instead, providers must use a certain code to bill Medicare for therapy and, since 2022, Medicare can perform a special review on claims over $3,000 for physical therapy and speech-language therapy combined and for occupational therapy.
- Review all Medicare notices to learn why Medicare coverage is being denied. If an appeal is appropriate, follow the directions on the notice regarding how to appeal. Send a letter with the appeal explaining why the therapy was medically necessary. If possible, attach a supportive letter from the patient’s physician and therapists.
Unfortunately, unfair denials still happen.
With support from the John A. Hartford Foundation, the Center for Medicare Advocacy provides this Toolkit to help Medicare beneficiaries and their families respond to unfair Medicare denials. The Toolkit includes self-help materials to advocate for coverage of Outpatient Therapy care that has been denied by providers, Medicare Advantage plans, and/or traditional Medicare.
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Download the toolkit |