Coverage was denied because I am "not improving". Is that allowed?
For Medicare and Medicare Advantage, no: coverage of skilled care cannot be denied on the ground that the patient is not improving when skilled services are needed to maintain function or prevent decline. Commercial plans may write a progress requirement into the plan, but the denial must then quote it, apply it to your records, and pass the mental-health parity test if the service is behavioural.
What to do, in order
- Step 1
Identify the plan type
Medicare and Medicare Advantage: the improvement standard is not a coverage test. Employer and marketplace plans: ask for the plan provision and the clinical criteria that carry a progress requirement.
- Step 2
Get the treating clinician's statement
Skilled care is needed to maintain the current condition or prevent or slow deterioration; without it, the expected decline is X. Progress notes that document maintenance goals matter more than goals that were not met.
- Step 3
For behavioural health, add parity
A progress requirement applied to therapy or ABA but not to comparable medical services is a non-quantitative treatment limitation the plan must justify with a comparative analysis. Ask for it.
- Step 4
Appeal with the standard named
Quote the rule that applies to your plan type, attach the clinician statement and notes, and ask for the specific criteria the reviewer used.
The deadline that applies
Medicare Advantage: 65 days from the notice (42 CFR 422.582); fast-track appeals for a discharge or termination of skilled care go to the BFCC-QIO by noon of the day before services end. ERISA and ACA plans: at least 180 days (29 CFR 2560.503-1; 45 CFR 147.136). The notice controls.
Calculate your date →Documents to gather
- The denial with the stated standard
- The clinician's maintenance-of-function statement
- Progress notes showing maintenance goals and risk of decline
- For behavioural health: the plan's comparative analysis request
Go deeper
Related questions
Where does the Medicare rule come from?
The Jimmo settlement and the Medicare Benefit Policy Manual: skilled services can be covered to maintain function, not only to improve it.
Does it apply to Medicare Advantage plans?
Yes. Medicare Advantage plans must follow Medicare coverage rules and cannot apply a stricter internal standard.
My commercial plan has a progress clause. Am I stuck?
Not necessarily. The clause must be applied as written and to your records, and for behavioural services it must pass parity.
Sources
Upload the denial letter. A senior reviewer reads it within 24 hours and tells you in writing whether it can be appealed and how. $0 upfront, 10% of what is recovered, nothing if we do not recover. Not a law firm.
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