Has anyone successfully challenged a Medicare decision?

Medicare doesn't pay for services unless they are 'making headway'. The rehab facility or wherever she is at, have to prove she is recovering or they stop paying. They do this to protect themselves and the patient so they cannot stay in a rehab unnecessarily. If a patient such as my grandma, fell and broke her ankle. They repaired it with surgery. She was kept in there at first with a cast unable to be walking. They instead focused on her arms and strong muscles claiming it will help with learning to use a sliding board to transfer (they ended up using a lift with her but they at least were trying according to the medicare forms). Then they switched to learning to use a wheelchair with a leg rest. She refused and just used her cast against medical advisement and they didn't bother to correct it but that was the skill they were working on. Then when they put a walking cast on her, I asked to take her home. They spent a day 'teaching her' how to walk with the boot on. Then released her saying all skills were met. They have to meet the skills they set forth for her. The facility might have to like suggested earlier, be creative with what can be done for needed skills. Skills such as learning how to deal with life with non walking. Opposite leg strengthening. Arm and hand strengthening. Learning her exercises. The facility will need to work with you as well as medicare to make sure medicare covers it.

The other thing is we had a supplement plan with AARP that kicked in to help with rehab. Medicare only covers a certain period of time, then if you have a supplement or even a state additive (she had one in CT that helped her stay in rehab longer after recovering from a broken neck and broken pelvic bone). The state gave her a few extra days (10 days I think) because she was on state assistance and that gave us the time it took to give her to really start being able to be mobile. They were concerned as we had there stairs to the front entrance at that time so she was going from bed bound, to wheelchair bound, to walker using to finally staircase climbing. She did amazing I must admit but that was a skill she needed to learn and medicare's time frame had ended and AARP had ended as well (broken necks are tough to heal from and she still even came home with a brace on for a while) so the state was able to give us a boost of 10 days so she came home ready and able to take on the world. She was an addict to pain killers and I had to learn how to ween someone off pain killers (terrible terrible experience but not for this question).

I hope you are able to get the help your wife needs.

The rules for Medicare are established in the booklet they send out to the participant annually. You'll have to have valid reasons to question EOBs.

Doesn't sound like failure to get well to me Katiekate, cause the doctors said they would give her 2 months to get better. How can an accountant say that she shouldn't have that chance, I hope they appeal it.

Expect a huge battle. They are becoming more and more difficult now because of the government's focus on reducing expenditures and the deficit.

I had a similar experience with my mother. She fell and broke her ankle. Medicare paid for rehab as long as she was progressing with the therapy. When there wasn't any further progress they stopped payment. We were warned this would happen and that we needed to file for Medicaid for the eventuality. We did that and then when she was able to resume her rehab Medicare took back over payments. If Medicare won't pay it, then no Advantage plan or Supplement will cover either. After this experience I got training through the Medicare SHIP program so I could help others navigate this confusing situation. The only insurance that might cover during the time that Medicare doesn't may be a Long Term Care policy but not very many people have them and they often don't cover the full cost.

MJB, there is a form in each Medicare EOB (Explanation of Benefits) letter. It's buried amidst other verbiage, so someone unfamiliar with the forms might have to look for it. And it doesn't ask for much information, which is why I drafted my own letter and contacted the hospital to see what support I could get from them.

I'm surprised the department store didn't offer to cover some of your mother's expenses, even if they weren't at fault. Sometimes good will is more important, but not always.

Our Medicare debt became a 12 month odyssey. My mother fell down in a Department store and broke her leg back in 2015. About 2 years later, Medicare sent a bill for $24,000 wanting reimbursement for provisional payments. Not being an attorney and unable to afford one, I grappled with how to file a proper appeal.  I sought advice from a well meaning insurance adjuster who thought Medicare was confusing and bundling other medical bills unrelated to the leg injury. My initial appeals were denied and the debt was finally referred to the Treasury Dept for collections. I finally realized Medicare had assumed my mother had received funds from a law suit or other 3rd party liability. Once I finally figured this out, I was able to produce the correct argument for the appeal. Finally, after months of stress and duress for my 87 year old mother and 93 year old father - the debt was resolved to zero.

I personally think Medicare needs to be simplified so the average lay person can navigate the system.
Also, it helps to be tech savvy to navigate the MyMedicare.gov site.  The other weird thing I discovered is that Medicare and the Treasury Dept do not share records (other than the debt) and forces people to start from scratch with an additional set of user names, passwords, authorized rep security clearances - and they do not send the previous appeals records - crazy right?

Get advice from knowledgeable nurses and social workers (insurance adjusters may not be the best advisers). The system is beaurocratic, but if you learn the rules- fair.

My mother was similarly on a non weight bearing status at rehab for 6 weeks before she could continue with PT using her broken leg.

However, the therapist assigned (after we complained about the first one who claimed she wasn't cooperating), found ways to provide PT anyway. The facility had a bed which could be raised and lowered. Mom sat on it and performed PT with her good leg, and possibly with the broken leg - I'm just not sure whether she did sitting exercises for her broken leg - this was way back in 1999.

Check with the doctor who performed the surgery and ask if your wife can do PT with the leg, on a non weight bearing status, or if she can do PT with her arms and other leg in the interim to keep them from atrophying.

I think the therapist who made the decision and passed it along to the admins and then to Medicare isn't thinking as creatively as she could be.

Or ask the doctor for a script for home therapy, to last until your wife can bear weight on that leg.

I did challenge Medicare on another issue, went to the second level of appeal but it was abandoned by Medicare. No final response. Medicare didn't even have the professional responsibility to respond after I appealed to that second level.

In the meantime, the hospital gave up the claim. This was a different situation though.

DON'T take this "laying down." Fight back; get a elder care attorney who's proficient in challenging Medicare decisions. If you need help in finding one, post back.

Also look up this link "Jimmo v. Sebelius" You should contact an Elder Law attorney.

do a search for "medicareadvocacy.org/jimmo-v-sebelius-federal-settlement-invalidated-medicare-improvement-requirement/"

You need to still be aware of the medicare hundred day limit and prepare for that eventuality.  

you have a good case here. they cannot predict the future and cannot base decision on anything but proof. see an attorney. I did win a case based on the truth.

Here is a New York Times article dated September 13, 2016, entitled "Failure to Improve Is Still Being Used, Wrongly, to Deny Medicare Coverage"

nytimes.com/2016/09/13/health/medicare-coverage-denial-improvement

From the article:

"Patricia Dudek, an elder law and disability law lawyer in suburban Detroit who represented the Kirbys in their appeal, started printing out relevant sections of the settlement agreement to show nursing home and home care administrators that the improvement standard was 'an old wives’ tale'."

AgingCare doesn't always allow "dot com" links to remain, so if the link I provided is removed, you still should be able to search online and find the article by the title and date I indicated above.

Here is the essence of the article:
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(quoting)

What matters, as the 2013 settlement of a class-action lawsuit specified, is maintenance. Medicare must cover skilled care and therapy when they are “necessary to maintain the patient’s current condition or prevent or slow further deterioration.”

A bit of background: Because the Centers for Medicare and Medicaid Services doesn’t publish statistics on why claims were denied, nobody knows how many millions of beneficiaries have been wrongly told that Medicare can’t cover continued services because the patients failed to improve.

But providers invoked the improvement standard so frequently that “one way or another, most people who had coverage denied were affected,” said Gill Deford, litigation director of the Center for Medicare Advocacy, a nonprofit legal organization.

Though never part of Medicare regulations, the improvement standard was written into the C.M.S. manuals that providers and claims administrators relied on. “It was a policy they followed for 30 years,” Mr. Deford said.

Patricia Dudek, an elder law and disability law lawyer in suburban Detroit who represented the Kirbys in their appeal, started printing out relevant sections of the settlement agreement to show nursing home and home care administrators that the improvement standard was “an old wives’ tale.”

Older patients with chronic and progressive diseases — dementia, Parkinson’s, heart failure — are particularly vulnerable to that now-discredited criterion. They’re unlikely to improve over time.

Yet therapy might help them stave off decline and hold on to their ability to function a while longer. Edwina Kirby, for instance, used a wheelchair, but hoped to be able to walk the eight steps into her bathroom at home.

By early this year, however, the Center for Medicare Advocacy was hearing from many sources that despite the settlement, providers and the contractors reviewing Medicare claims were still denying coverage when beneficiaries didn’t demonstrate improvement.

The Centers for Medicare and Medicaid Services showed no inclination to take further steps, so the plaintiffs’ lawyers went back to court, seeking enforcement of the agreement. The federal judge in Vermont who oversees the settlement ruled in August that C.M.S. didn’t have to further revise its manuals, but did have to mount a better educational campaign.

Of course, patients and families have the same right to appeal coverage denials that they’ve always had. (A notice to this effect is buried somewhere in the paperwork they sign.) They also have the same odds of prevailing they’ve always had: very low, said Judith Stein, the executive director of the Center for Medicare Advocacy.

Patients generally have 72 hours to appeal, a process that involves seeking a “redetermination” and then, if that fails, a “reconsideration.” If families go all the way to a hearing before an administrative law judge, Ms. Stein said, they have a good shot.

But most families don’t persevere, in part because they can’t afford to pay for care while the appeal proceeds. (If they do spend their own money, though, they can appeal for reimbursement.)
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(end quoting)

PLEASE READ THE ENTIRE ARTICLE AND FOLLOW ALL LINKS FOR COMPLETE INFORMATION.

My 92 yo mother is immobile and needed to see a specialist. We live rural. The specialist was 30 minutes away. NH called me (at work) to let us know for her to keep the appointment she'd have to be transported via ambulance. I said that was fine, because how else would she get there? I don't have a handicapped vehicle and live an hour away. So, even though the Dr. ordered this visit, I learned the long and hard way (after an unsuccessful appeal) that Medicare won't pay for ambulance transport to this necessary appointment. That was a $3000 error for a 30 min ride each way. Sorry to be a downer, but it's hard to fight city hall. Many times it just depends how the institution "codes" things. CHECK CHECK CHECK EVERY SINGLE BILL TO MAKE SURE IT IS CODED CORRECTLY. It becomes a full time job. And a real joy stealer. I hate it. And, the worst thing is, for all my "work" for Mom's finances she's in no better health for it. Breaks my heart.

Medicare rules are that they cover only to a max of 100 days...and only if 1) the stay was immediately preceded by an acute care hospital stay, and 2) the patient continues to make forward progress.

Also...the Medicare supplemental policies only cover what Medicare has approved... they pay the difference between what Medicare paid and the total bill. If Medicare denies...supplemental does not pay.

So, the facility has reported the failure to improve. That is the basis of the denial.

We had a similar issue. Mom broke hip, we had it pinned. Pin slipped, bone was deteriorating and she was unable to make any progress with therapy, her dementia didn't help matters. She was taken off medicare. NH agreed to try therapy 10 more days. We filed an appeal , although NH agreed to try more therapy our appeal was denied. It certainly doesnt hurt to file an appeal, good luck.

Yes I have but I was in the insurance industry before being on disability. The reason for Medicare's denial is that she is in there because of the leg and not the Dementia. You will need to get the appeal forms filled out by the Drs saying she has to stay there. If the answer is no a Medicare Supplement or Advantage plan should pick it up.