Skilled care does not require improvement
Medicare covers skilled nursing and therapy to maintain a condition or slow decline, not only to improve it; the Jimmo settlement forbids denials based on an 'improvement standard' or a 'plateau'. Any letter that says the patient is 'not progressing' or has 'reached maximum benefit' is using the wrong test.
When it applies
- Skilled nursing facility, home health, outpatient therapy and inpatient rehab under Original Medicare and Medicare Advantage
- Chronic and progressive conditions: Parkinson's, MS, ALS, stroke recovery, dementia with skilled needs
Where it does not
- Care that requires no skilled personnel at all (custodial care remains uncovered)
- Commercial plans, unless the plan document adopts Medicare criteria
The sentence to put in the appeal
“Coverage of skilled services does not turn on the potential for improvement. Under 42 CFR 409.32(c) and the Jimmo v. Sebelius settlement, skilled nursing and therapy are covered where they are needed to maintain the patient's current condition or to prevent or slow further deterioration. The denial's reliance on [lack of progress / plateau / maximum benefit] applies a standard Medicare has disavowed.”
Replace the bracketed parts with your facts. Cite the regulation exactly as written; quote the plan’s own wording next to it.
How to use it
- Step 1
Find the improvement language in the letter
'Not making progress', 'plateaued', 'no further functional gains': quote it.
- Step 2
Have the clinician write to the maintenance standard
What skilled service is needed, why an unskilled caregiver cannot safely provide it, and what deterioration it prevents.
- Step 3
For terminations, use the fast-track appeal
A Notice of Medicare Non-Coverage can be appealed to the QIO by noon of the day before coverage ends, and coverage continues while it decides.
Worked example
Home physical therapy for a patient with Parkinson's was terminated for 'no functional improvement'. The appeal cited 409.32(c), attached the therapist's maintenance plan, and the QIO reversed.
Illustrative composite; details vary by plan and record. Outcomes are not guaranteed.
Go deeper
Sources
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