WASHINGTON • Two federal courts have ruled that the federal government is using overly strict standards to determine whether older Americans are entitled to Medicare coverage of skilled nursing home care and home health care.
Medicare will pay for those services if they are needed to maintain a person's ability to perform routine activities of daily living or to prevent deterioration of the person's condition, the courts said. Medicare beneficiaries do not have to prove that their condition will improve, as the government sometimes contends, the courts said.
The rulings are potentially significant for many people with chronic conditions and disabilities like multiple sclerosis, Alzheimer's disease and broken hips. Skilled care may be reasonable and necessary and covered by Medicare even if the person's condition is stable and unlikely to improve, the courts said.
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The government has not said whether it intends to appeal either decision.
Rep. Joe Courtney, D-Conn., welcomed the decisions. "People with chronic conditions are being denied care in the mistaken belief that Medicare requires improvement of a person's condition as a prerequisite for coverage," Courtney said Monday. "That's not in the law. It's urban legend."
In one case, the district court in Pittsburgh said Medicare officials had used the wrong legal standard in denying coverage of skilled nursing home care to an 81-year-old woman, Wanda Papciak.
After hip replacement surgery, Papciak received skilled nursing care, physical therapy and occupational therapy in a nursing home. Medicare terminated coverage after five weeks, saying her condition had not improved and was unlikely to improve.
In reversing the decision of Medicare officials, the court said Papciak needed skilled nursing home care "to maintain her level of functioning" and to prevent her condition from deteriorating.
In the other case, a federal district judge in Vermont ruled that Medicare had improperly denied coverage for certain home health services provided to a 66-year-old woman who had had two strokes.
The judge, Christina Reiss, said that even though the patient, Sandra Anderson, might have been in stable condition, she still needed home health care to prevent deterioration of her functional ability. A Medicare beneficiary "need not risk a deterioration of her fragile health" to justify continuation of skilled care, Reiss said.
A group of 17 House Democrats, led by Courtney, recently sent a letter to the administration of President Barack Obama objecting to its interpretation of the law.
"Beneficiaries are frequently told that Medicare will not cover skilled services if their underlying condition will not improve," the letter said. "For example, as people with multiple sclerosis are often not likely to improve, skilled services such as physical, occupational and speech therapies that are necessary to slow the progression of the disease, or maintain current function, are denied. As a result, these individuals' conditions deteriorate — frequently leading to more intense, more expensive services, hospital or nursing home care."