Has anyone made a successful expedited (fast) request on a claim denied by a Medicare Advantage plan?

We recently successfully appealed a denial for rehab services by our Medicare advantage plan after my husband's hip surgery, but it took a lot of doing. First, the person needs to be admitted to the hospital for 3 days before Medicare will even consider further stay at a skilled nursing facility (for rehab). You mention that your family member is in the hospital under "observation" status, and that does not count as admission, even if it's for several days. Second, it really helps if you can get a doctor to go to bat for the person; after initial denial, you can ask for a "peer to peer" review where the person's doctor talks to a medical person at the insurance company. At the hospital where our husband was, the discharge coordinator handled all this. Unfortunately, if the patient is not a candidate for short-term rehabilitation services, with a likelhood of improving and being able to go back to live where they were before, it's unlikely Medicare would pay for further care. I'm surprised local facilities would not admit the person as self-pay, but possibly they may feel he/she not a candidate for short-term rehab. and that he/she is better suited to long term care. We actually had my husband get transferred from the hospital to a snf as self pay while the appeal was going through. We had to pay for one month up front, but got it all back after he was discharged because the appeal was successful and the Medicare advantage plan paid. If your relative is going to need LTC and can enter as self-pay, that may be the best solution; when their assets run out, then they'd have to apply for Medicaid.

Needtowashair, I'm aware that Medicare does not have an improvement standard to provide coverage for therapies such as PT, OT and speech. However, Medicare (Part A) will not pay for more than a certain number of days at an inpatient rehab place or skilled nursing facility. If the stay is deemed to be medically necessary, Medicare will pay for 20 days at the full rate, then with a hefty coinsurance for days 21-100. https://www.medicare.gov/coverage/skilled-nursing-facility-snf-care If a person is in LTC, memory care, or assisted living, Medicare (Part B) can pay for therapies needed to maintain functioning but they won't pay for the daily "room and board." I suspect the problem with the OP's relative is that he/she, for whatever reason, is not deemed to be medically needy enough for placement in a skilled nursing facility. This doesn't mean the person is safe to go home, and a lot of care, assistance, and medical management may be needed. Best bet may be to try for a facility that will take private pay, continue to appeal the denial, and in the meanwhile the Medicare advantage plan will pay for any therapies the person needs.

You are being denied because the hospital is keeping your loved one under observation and not admitted. Get on the hospital and get them to admit your loved one.

Observation status doesn't qualify for any rehab or after care. It is just ridiculous that hospitals don't admit patients but keep them for days under observation knowing full well that the person will not get after care but will have deteriorated from laying in bed for days.

Get the hospital to change the status. That is the 1st step.

Is it time for long term care? That will never be approved by insurance, they don't cover that care.