Medicare. Elder Care. Advocacy.

Notice of Medicare Non-Coverage Explanation

As my mom was being released from a rehab facility, we first issued an appeal. We knew that she was unable to live on her own with her health issues. We also knew my father would not be able to carry the load. After the appeal was denied by Medicare, we issued a second appeal. Most people are unaware that you can appeal an appeal with Medicare. Here’s what we learned.

When in a “Skilled Nursing Facility Level of Care — General” as found in the Medicare Benefit Policy Manual, Chapter 8, Section 300.

Medicare guidelines indicate that care in a skilled nursing facility is covered if ALL the following four factors are met:

1. Care your doctor ordered can only be provided by or under the supervision of a nurse or therapist (see sections 30.2–30.4 of the manual)
2. You require nursing care on a daily basis or therapy at least 5 days a week (see section 30.6 of the manual)
3. This care cannot be provided in the home or with the assistance of home health care (see section 30.7 of the manual)
4. This care must be reasonable and necessary for your specific situation and needs. In addition, the length of the treatment plan and amount of services requested must…