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Repeated denials for in home services

diagnosed2016

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I’m at my wits end here. PALS has almost no functional movement aside from head/upper torso and a few fingers. He uses his bipap about 20hrs a day. He can be left alone for an hour or so if he’s reading a book on his computer but he can’t move his hands so he’s stuck there if I’m not home. Our insurance will cover 35hrs weekly of ot/pt/nursing. We were receiving nursing visits and PT visits but now are being denied anything based on the fact that he has a caretaker living in the home (me). We have social workers on our case, multiple case workers, but the company who handles authorizations is hell bent on me doing everything. Has anyone heard of a situation like this?? We have 2 small children, no family and no other help and I’m slowly drowning.
 

lgelb

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What kind of insurance is it?

Do you have a case manager with the plan?

What's the name of the authorization company?

Is the ordering physician's office working with you to appeal the denial? If they are ignoring requests for clarification, nothing more will happen. My guess is they have failed to fully justify the skilled care. There is an art to it.

I can't answer what they can and can't authorize because it depends on your plan certificate, unless it's regular Medicare, in which case the "skilled care" criterion below applies.

The Center for Medicare Advocacy has some slightly dated but still helpful information on their site. One snippet:

"To receive Medicare coverage for home health services, some type of skilled care is always required. The skilled care may be nursing care (must be reasonable and necessary, intermittent, and not solely needed for venipuncture for the purposes of obtaining blood sample).

Or the skilled care may be physical therapy, speech-language pathology services, or occupational therapy (a continuing need). MBPM Chapter 7, § 30.4.

Home health aide alone is not a covered service."

Best,
Laurie
 
Last edited:

diagnosed2016

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Mynexus is the auth company, it’s a Medicare plan. The neurologist and PT have both had phone calls with their Dr team, in addition to letters written, etc. For PT we are being denied because he they say he has someone at home who can perform PT and doesn’t need a high level of care. I just don’t understand how we can be denied physical therapy based on ME.
 

Narrowminded

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Diagnosed - I am so sorry you are facing this situation. I faced similar and Brian was on a vent. However in my state they changed rules and any nurse that was not vent certified could not enter the home. None in the area were. And with a vent, you are not permitted and aide.

What I had to do was reach out the our local ALSA and they gave me a small grant which I used to hire private duty nurses. In your case you could get aides, so the money, if you Assoc. does grants could go a bit further. Best to you as you work this out. I know how rough it is.

Hugs
 

Jrzygrl

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Insurance sucks when in comes to in-home care.

Our insurance would only cover skilled nursing, and DH does not qualify. They will send a PT/OT out with a doctors script, but for continued care he has to "show improvement". Not happening, so they come for a few sessions to train me and then are out. The PT provider we are now using has a "personal pay" option, so now we're paying out-of-pocket for continuing PT. Not cheap, but I want to know he is getting the correct care. He is in a similar situation as your husband as far as physical mobility. He only uses a Trilogy at night.

Luckily, our local ALS Association has a grant program where they will pay for up to 12 hours a week for an aide. Please check with your local branch to see if they have anything to offer. It's the only way I can get out of the house for more than 15-20 minutes.

Keep pushing.

Hugs.
 

vltsra

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This is total BS. Our health care system does not recognize the sacrifices and burdens it puts on caregivers. Not to mention the fact that caregivers' health suffers which ends up costing the system more. I am my husband's sole caregiver, no help from anyone else. I have hired a caregiver out of pocket but am fortunate to be in a position to be able to do so, at least at this point, where others are not.

V
 

ReginaS

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Not sure if this is relevant: The PT at the ALS clinic has given us a handout that there is a law (?) that should guarantee ALS patients on Medicare (not sure if it is only medicare) continued PT also if there is no improvement - only for maintenance.
We had PT through a home health care program and pALS was discharged after 3 sessions. Now they are coming back and the sessions are great.
I think our ALS clinic, physician and PT educated the home health people.
 

lgelb

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Yes, there was a policy change to allow for "maintenance," not requiring improvement. Unfortunately, ALS was not one of the diseases mentioned so interpretation may vary. That was the "dated" aspect of the site I mentioned.

The hyperlink in my post was, however, the current manual.

Cali, you have a Medicare Advantage plan? Who's the carrier, like Anthem?

It's true that they'll try to say you can do the regimen of PT once it's laid out, esp. once it's only "passive" ROM (he can't do exercises himself). There would be a couple of arguments against that: disease progression, safety (e.g. protecting joints that are at risk of dislocation), immobility potentially leading to loss of skin integrity/pressure injuries.
 

Nikki J

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The change happened based on a court decision Jimmo vs Sebelius. https://www.cms.gov/medicare/medicare-fee-for-service-payment/SNFPPS/downloads/jimmo-factsheet.pdf

There were multiple individuals and the case was also joined by a several advocacy groups. I don’t think that ALS is not covered by the no need to show improvement / maintaining/ preventing deterioration standard set forth. I have successfully got PT for ALs patients by citing this case to the relevant providers. Hopefully the pt and others can document the need

As Laurie says the issue is likely they are claiming the current need is not for skilled services
 

lgelb

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Yes, Nikki is correct and no, I didn't mean to imply that ALS wasn't technically covered, just that the reporting/punditry around the decision focused on a few diseases and ALS wasn't one. Insurance/home health tends to be very literal and conservative (not to mention clueless about ALS).

So yes, it's worth citing the decision and the need for skilled care.
 

Jrzygrl

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Wow! I just printed the court decision out and will be taking it to our ALS clinic with me tomorrow. DH just got Medicare in January. Fingers crossed they will now cover continuing PT. This has been one of my biggest pet peeves.
 

MarieLaure

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I don’t understand half of the legal details but this thread must be so helpful to people who need the information. That’s another reason why this forum is a friendly good place.
Strength thru paperwork and legal arguments!
Thanks to those who share their knowledge
 

diagnosed2016

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We know we don’t have any caregiving covered, we just want the PT we have been getting and weekly nursing visits for wellness check so everything is not on me.. It’s so insane to me that insurance companies can force a caregiver to do everything. Their authorization team is going directly opposite to what his dr has ordered, despite numerous calls and letters.
 

lgelb

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Don't ever say "wellness check" in documentation. That's not a medical necessity for skilled care. I would put the argument into the PT.
 

ReginaS

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Our home healthcare will not provide services if it is just for PT (for example).
We had to have a need for at least 2 of the following: nursing, PT, OT or speech therapist.

I believe our physician wrote that there was a need to evaluate things for safety and train me on equipment.

A nurse does the 'intake' exam and then they sent PT, OT and speech therapist. The speech therapist did the evaluation for the tobii device and OT mainly trained me on the hoyer. PT was most fun and beneficial. I am not sure how things will continue when OT and speech therapist "discharge" - which is happening soon.
 
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