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The facility says part A Medicare will deny payment because she can not weight bare and her admission to facility was to improve after her surgery.

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I’ve never heard of Medicare denying coverage for this reason. You need to go to the social worker at the facility and ask for more detail.
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AlvaDeer Sep 2019
If the PT people are charting that the patient cannot participate and they do not expect that to change then it can happen. When people go to rehab and think they can refuse PT or not participate it can happen fairly quickly but there is usually care plan discussion, often family asked to participate in planning first. At least my experience of it in California.
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Are you saying she is in a rehab facility post operative to regain mobility. But the rehab is saying shes not improving? And so now the Medicare coverage is ending due to lack of improvement? I believe theses evaluation periods usually occur every 2 weeks, so you may be able to appeal to Medicare/supplemental insurance provider to ask for another few week increment. What is the facility recommending for “next steps”?
Others may chime in with more info, or please clarify if I haven’t understood the situation correctly.
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Maybe they aren’t covering because she has no more paid rehab days.
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This is the old "no improvement", "plateau", "new baseline" BS that many facilities still try to shovel. Don't fall for it. Medicare themselves tell you how to fight it. Note that the first two appeals are by another private healthcare provider so you will tend to lose those. The third and up are by the government. Your best chance is when you hit those. The law is pretty clear. Also, a written appeal seems to work better than an oral one over the phone. When I did the oral one on the phone, I read a statement I wrote citing all the relevant laws. The person on the other side didn't seem to be doing any typing and at the end, she just said "The family disagrees." Not surprisingly we lost that appeal.

Here's the medicare website giving you links to information you need to appeal this. Call your city or county ombudsman as well. But don't be surprised if they've never heard of it either. Mine towed the "no improvement" line as well until he looked into all the pointers I gave him, consulted a lawyer and then he called back and told me I was right.

https://www.cms.gov/Center/Special-Topic/Jimmo-Center.html
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AlvaDeer Sep 2019
Do you think the Lawyer consult was what tipped it into the "winning" because I haven't heard of anyone winning yet. Hope they have good luck here. But one can also understand that, if someone cannot participate in rehab therapy, the Government wouldn't want to pay for that specialized care, and would think they have reason not to. The appeal is sure worth a try but I would hesitate to hire a Lawyer and invest that; I think the ombudsman is an excellent idea.
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This is about correct coding. She was apparently admitted to rehab for rehab, that is to say for walking and getting around again. However they code that. But she cannot now participate. If she cannot improve through rehab, yes, Medicare will not pay. Are there open wounds of any kind? Is there anything you can think of that you could ask the MD to use to "buy" her more time?
Why is she unable to put weight on this surgical leg? Does anyone have any idea? If not, I am afraid she will be discharge, in a WC and possible forced to use a wheel chair ongoing. Is she suffering from dementia? How old is she? Are there other conditions as well?
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Did the doctor who performed the surgery either provide a statement, or something to the rehab facility advising that she's to be non weight bearing?   He or she should be involved, to affirm the non weight bearing status so PT can continue on strengthening w/o weight bearing.

My mother experienced this; we went back to her ortho doctor; he wrote a statement and we delivered it to the rehab facility.  

We had also gone back to him b/c a therapist determined that my mother wasn't able to progress.    The doctor's letter and our challenge addressed that.  He was placed at another facility and my mother got a new therapist,  a very compassionate one. 

I agree that coding is involved, but so is the doctor.
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