Has anyone successfully challenged a Medicare decision?

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Wife with Alzheimers fell and broke her leg. It is so close to replacement knee that it cannot be repaired. Treatment is to keep off leg for 2 months and then see if walking with assist is possible. She was transferred to memory care/rehab facility. Medicare paid for 2 weeks and then denied coverage, allowing that it might start again when walking is possible.

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