Appeals Documentation

Also see: Step-by-step overview of the Medicare claims appeal process.

Common Reasons Inpatient Rehabilitation Claims are Denied

  • No reasonable expectation of improvement in quality of life or level of functioning
  • 3 hours of skilled rehab not provided
  • Multidisciplinary care not required or provided
  • Documentation does not justify the length of stay, etc.
  • Therapy notes did not match the multidisciplinary team notes, or
  • Notes did not match the information contained in the Patient Assessment Instrument
  • Services available in a less intensive setting
  • Premature discharge from acute facility
Source: TriSpan, 10/05

Critical Elements in Appealing Rehabilitation Claims

  • Section 110 of the Medicare Benefit Policy Manual, Chapter One
  • Title 42 CFR, Part 412 (The "75% Rule")
  • Local Coverage Determination (LCD), if applicable (Example: BCBS of Georgia L18887)

Best Practice - Appeal Documentation

  • Include specific, detailed information from the patients chart referencing specific pages of the medical record.
  • Show that patient met criteria found in the Medicare Benefit Policy Manual 100-2, Chapter 1, Section 110.1 and any applicable LCD
  • Contain all supporting evidence & documentation.
  • Include table of contents and a paginated chart.

 Lessons from the Field

Alabama Medical Review of LCD A-03-03
Replacement of Lower Extremity Joint
  • May 2005 – Error Rate 88.78% ($1,585,067 charges denied of 107 Claims reviewed for 49 Providers)
  • December, 2005 – Error Rate 91.25% ($1,034,375 charges denied of 100 Claims reviewed for 42 Providers)
  • Majority of denials because “documentation in the medical record did not provide sufficient justification for the services rendered.”
Redetermination Decision: Denial upheld 

“This patient was admitted to the acute hospital for pneumonia, requiring mechanical ventilation. She was admitted to XXXXXXX for IRF services for extremity weakness & numbness of the feet with impaired proprioception. The patient was experiencing decreased mobility & balance. While it appeared that this patient had deficits that needed to be addressed, there was no documentation submitted that established the need for an inpatient rehabilitation hospitalization for this patient. It appeared that the patient’s therapy could have safely & effectively been provided in a less intensive facility.”

NOTE: Local coverage decisions was not referenced, only Medicare Benefit Policy Manual

Reconsideration Decision: Denial upheld

“In this case, a panel of clinical experts consisting of a physician & a licensed healthcare professional reviewed this case & determined that based on LCD #L19997 Medicare coverage criteria was not met. In order to receive covered OT services, the services must be of such a level of complexity and sophistication that they can only be performed by a qualified Occupational Therapist, or under his/her supervision. There must be a reasonable expectation that the patient’s condition will improvesignificantly within a reasonable & predictable time frame. The documentation does not support reasonableness & necessity. There was no signed plan of care submitted for review nor was there any physician input in the beneficiary’s chart. Additionally, OT session notes did not sufficiently document the unique skillsof an Occupational Therapist.”



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