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Medicare Will Reconsider Therapy Maintenance Care Denials Because of Lack of Functional Improvement 2011-2014. Reconsideration Forms and Instructions Available.

The Jimmo VS Sebelius settlement agreement provides for a CMS review of therapy claims in which therapy services were denied on the basis that the patient had no restoration or improvement potential. Beneficiaries whose claim for therapy was denied between January 18, 2011 and January 23, 2014 may request a re-review of their claim denial in light of the finding that there has never been a statutory requirement for functional improvement to justify medically necessary skilled care.

The Settlement Agreement goes back to the date the case was filed, January 18, 2011. The Agreement establishes a process called "re-review" for Medicare beneficiaries who received a denial of skilled nursing facility care, home health care, or out-patient therapy services (physical therapy, occupational therapy, or speech therapy). After the government completes the revision of its policy and guidelines, and educates Medicare decision-makers, individuals will be able to get a re-review of these claims. The denial must have come from Medicare and must be for services that were actually received, but not paid for by Medicare. The Medicare denial must have become final and non-appealable after January 18, 2011 and before the end of the educational campaign (expected to be by the end of 2013). This means that claims must have been submitted to Medicare and denied, and the normal deadline for further appeal must have expired, The beneficiary may have tried appealing the denial through the regular Medicare appeal system; it does not matter at which level the beneficiary stopped as long as the outcome is a denial and the deadline for further appeal has passed. (From Frequently Asked Questions about Jimmo Settlement, Center for Medicare Advocacy,

Request forms to request re-review of Medicare claims related to the Jimmo settlement agreement may be downloaded from Q2 Administrators, the Medicare Contractor responsible for the review at
or from the Center for Medicare Advocacy, who won this landmark decision on behalf of Medicare beneficiaries at     Instructions for filing the form are given on the form.

CMS policy manuals have been revised Be aware, however, that some of the lower level Medicare Contractor documentation (Local Coverage Determinations) remain in place and have not been modified to comply with the Jimmo agreement. Any further denials after January 23, 2014 should be processed through the normal Medicare appeal process.