Our mother's Medicare Advantage plan is denying her doctor recommended stay in an inpatient rehab facility because it is not "medically necessary."
According to Medicare Guidelines, which the plan is supposed to follow, her stay should be covered if her doctor has certified that she requires:
• intensive physical or occupational rehabilitation (at least three hours per day, five days per week) – Her doctor has certified
• at least one additional type of therapy, such as speech therapy, occupational therapy, or prosthetics/orthotics – Her doctor has certified
• full-time access to a doctor with training in rehabilitation, including at least three visits per week, and – Her doctor has certified
• full-time access to a skilled rehabilitation nurse – Her doctor has certified
Prior to January 1 her Medicare Advantage plan was through a different company and they had covered her first 7 days. Both companies state that they follow Medicare Guidelines. How can one interpret them differently and what constitutes "medically necessary?"
I would also send a copy of the denial to the doctor who made the recommendation and ask his office to support your appeal.
The doctor is aware of the denial and sent his recommendation as part of the appeal.
I would like an explanation of what constitutes "medically necessary" under Medicare Guidelines. It would seem it is up to the doctor, not the insurance company, to make that determination.
This is a typical response when the physician uses the wrong code. Have them resubmit.