Equipment, home health and therapy limits

Durable medical equipment (such as a wheelchair, a breathing machine or a hospital bed), home health care and therapy (physical, occupational, speech) are all denied for the same few reasons. The plan says you do not need it, you need less of it, or you have reached a limit. Each reason has a different answer.

What this means

• “Not medically necessary.” The plan says the item or service is more than you need. Answer with your doctor’s letter and the plan’s own criteria. The not medically necessary guide shows how.
• “Visit limit reached.” The plan says you have used all the visits it covers. First check whether the limit is a hard cap or can be raised for medical necessity. The federal external review rule gives this example: a visit-limit denial where more visits depend on medical necessity is reviewable. The plan document says which kind you have. Ask for it in writing.
• “Custodial care.” The plan says the help you need is personal care and not skilled care. Your doctor, nurse or therapist must show the skilled need: what a trained person does that you or a family caregiver cannot safely do.
• “Care is ending.” The plan or provider says services will stop. If the plan had approved a course of care, cutting it short is a denial, and the plan must give notice far enough ahead for you to appeal and get a decision first. Non-grandfathered plans must provide continued coverage while the appeal is pending on those terms.

Medicare. Medicare coverage of skilled nursing and skilled therapy does not depend on whether you are expected to improve. Under the Jimmo settlement, the Centers for Medicare & Medicaid Services confirmed that skilled care is covered when needed to maintain your condition or to prevent or slow decline, in skilled nursing facility, home health and outpatient therapy settings. The regulation says that restoration potential is not the deciding factor in whether skilled services are needed.

If a skilled nursing facility, home health agency or comprehensive outpatient rehabilitation facility tells you Medicare-covered services will end (or, in Original Medicare, a hospice), you should get the Notice of Medicare Non-Coverage at least two days before. In Original Medicare you must ask the reviewer (the quality improvement organization) for a fast appeal by noon of the day after you receive the notice, and a decision is due within 72 hours. For a Medicare Advantage plan the request deadline is also noon of the day after the notice, and the burden of proof is on the plan. A late request is still accepted, without the deadline or liability protection. Check the date on your notice, which controls.

If Original Medicare denies a service as “not reasonable and necessary” or as custodial, it may still pay if neither you nor the provider knew or could reasonably have been expected to know it would not be covered. You are treated as knowing only if you were given written notice. In Original Medicare a provider may give an Advance Beneficiary Notice of Noncoverage before the service. Read it before you sign.

Medicaid for people under 21. The state must cover medically necessary services to correct or ameliorate conditions, whether or not the state plan normally covers them. If a child or young adult is denied equipment or therapy because a service is not covered or a limit is reached, ask whether this standard applies. The state decides medical necessity case by case.

What to do

1. Read the denial for the specific reason. Note whether it says necessity, limit, custodial or ending. (You.)
2. Ask for the plan’s policy and criteria. Equipment often has its own written criteria. Use the plan documents request and the clinical criteria request. (You.)
3. Ask your doctor or therapist for a letter. It should describe your diagnosis, your function (what you can and cannot do), what you tried, why this equipment or number of visits is needed, and the risk if you do not get it. Include measurements, test scores and dates where your therapist has them. (Your doctor or therapist.)
4. Ask the supplier or agency for records. Ask what they sent the plan and whether they can supply order forms, delivery records or visit notes. (The supplier or agency.)
5. File the appeal. Use the equipment appeal letter. Employer and non-grandfathered individual plans must allow at least 180 days after you receive the denial. Check the date on your notice, which controls. (You.)
6. For ending care, ask for a fast review right away and ask your doctor to certify urgency. For a Medicare notice, follow the notice’s phone number and deadline. (You and your doctor.)
7. Request external review after the final internal denial if the reason involves medical judgment. You have at least four months. (You.)

What the plan may say, and what to say back

“You have reached your annual visit limit.” Ask for the plan language on the limit and whether more visits can be approved for medical necessity. If they can, have your therapist submit measurable goals and progress.

“This equipment is a convenience item.” Have your doctor explain the medical purpose in your case and what happens without it.

“You are not improving.” If you have Medicare, point out that improvement is not the standard; care that maintains your condition or slows decline can be covered. For other plans, ask the plan for its written standard.

The rule

Skilled care is covered in Medicare when needed to maintain a patient’s condition or to prevent or slow decline; the restoration potential of a patient is not the deciding factor. Jimmo settlement, Centers for Medicare & Medicaid Services

Watch for

• Paying up front. Try not to pay for equipment in full before the denial is decided if you can avoid it. Ask the supplier about its refund policy.
• Plan type. Medicaid and other plans may have different lists of covered equipment and different limits. The plan document controls.
• Dates. For ongoing care, the dates on the notice matter more than the length of the appeal process.

What next

• Not medically necessary: the main argument for equipment and therapy denials.
• Keep treatment going during an appeal: your rights when approved care is cut.
• Medicare fast appeals: the one-day clocks for ending care.
• Ask your doctor for a letter: how to get a useful letter.