Medicare Coverage for Physical Therapy
Original Post: My husband has PPS and was recently diagnosed with spinal stenosis. He recently underwent two extensive surgeries within 8 days. (The surgeon was not satisfied with the results shown on the MRI after the first surgery and wanted my husband to have the best results possible which led to the second operation).
We are now home after 3 weeks of rehab in the hospital. He is very much in need of PT and OT and is confined to the house. I am having a difficult time convincing the Health Service Agency that PPS are not limited to the amount of PT they are prescribed by their physicians to have. Could you please point me in the right direction? I want my husband to have every chance possible for a good recovery.
Dr. Bruno’s Response: PT does not always have to be limited by "showing improvement" but can be paid for to maintain in chronic illnesses . . . here is an article by Susan Jaffe from the NY Times:
Therapy Plateau No Longer Ends Coverage
No “Improvement Standard” is to be applied in determining Medicare coverage for maintenance claims that require skilled care. Medicare has long recognized that even in situations where no improvement is possible, skilled care may nevertheless be needed for maintenance purposes (i.e., to prevent or slow a decline in condition). For example, the longstanding SNF level of care regulations, specify that the restoration potential of a patient is not the deciding factor in determining whether skilled services are needed. Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities.
“ ‘The coverage can go on for years and years, if your doctor orders it,’ said Ms. Murphy, the center’s associate director, who added that patients must be homebound (though not bedbound) and need intermittent care — every couple of days or weeks – that can only be provided by a physical therapist, nurse or other trained health care professional. When physical therapy is provided as part of Medicare’s home health benefit, the therapy dollar limits may not apply.”
Medicare currently allows maintenance treatment. But, your husband is getting recovery treatment which is limited by maximum medical benefit. His doctor should ask for more sessions.