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Joachim Zuther, Lymphedema Specialist. Read more
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Tactile Medical

Proposed Settlement to Broaden Medicare Coverage for Chronic Conditions


Dear Readers!

Today an article appeared in the New York Times outlining the proposed settlement of a lawsuit that challenged the government’s practice of denying some coverage to patients whose condition was not improving. This settlement will certainly have an effect on current procedures in terms of Medicare coverage for patients affected by lymphedema.

Under the terms of the settlement, which is expected to be approved by judge Christina Reiss, the chief judge of the Federal District Court in Vermont in coming months, Medicare would not deny skilled nursing care and various forms of therapy for beneficiaries, regardless of their prognosis.

Medicare is required by law to cover healthcare services that are “reasonable and necessary for the diagnosis or treatment of illness or injury.” In practice however, Medicare has at times denied coverage for skilled care for beneficiaries whose condition was not considered likely to improve under what came to be known as the “improvement standard.” Under this standard, individuals on Medicare suffering from disabilities or chronic conditions that were not expected to improve, might have been denied coverage for physical therapy that could help keep them stable or prevent a further decline in their health.

The proposed settlement would allow Medicare beneficiaries with disabilities or chronic conditions to qualify for Medicare benefits for physical, speech and occupational therapy, and skilled nursing services that the program would not pay for previously.

If the proposed settlement is accepted by the court, the Centers for Medicare and Medicaid Services (CMS) will re-write portions of its Medicare Benefit Policy Manual and include rules to “maintain the patient’s current condition or prevent or slow further deterioration” for skilled nursing and home health services.

Here some excerpts on revisions from the settlement document:

Manual Revisions

1. The agency will revise the relevant portions of Chapters 7, 8, and 15 of the Medicare Benefit Policy Manual (MBPM) to clarify the coverage standards for the skilled nursing facility (SNF), home health (HH), and outpatient therapy (OPT) benefits when a patient has no restoration or improvement potential but when that patient needs skilled SNF, HH, or OPT services (SNF, HH, OPT “maintenance coverage standard”).

The agency will also revise the relevant portions of Chapter 1, Section 110 of the MBPM to clarify the coverage standards for services performed in an inpatient rehabilitation facility (IRF).

2. The manual revisions to be made pursuant to this Settlement Agreement will clarify the SNF, HH, and OPT maintenance coverage standards and IRF coverage standard only as set forth below in Sections IX.6 through IX.8.

Existing Medicare eligibility requirements for coverage remain in effect.

Nothing in this Settlement Agreement modifies, contracts, or expands the existing eligibility requirements for receiving Medicare coverage, including such requirements found in: a. Post hospital SNF Care, as set forth in 42 C.F.R. Part 409, Subparts C and D, and related sub regulatory guidance;

b. Home Health Services, as set forth in 42 C.F.R. Part 409, Subpart E, 42 C.F.R. Part 410, Subpart C, and related sub regulatory guidance;

c. Outpatient Therapy Services, as set forth in 42 C.F.R. Part 410, Subpart B, and related sub regulatory guidance; and

d. Inpatient Rehabilitation Facility services, as set forth in 42 C.F.R. Part 412, Subpart P, and related sub regulatory guidance.

3. CMS will revise or eliminate any manual provisions in Chapters 7, 8, and 15 and Chapter 1, Section 110 of the MBPM that CMS determines are in conflict with the standards set forth below in Sections IX.6 through IX.8.

Maintenance Coverage Standard for Therapy Services under the SNF, HH, and OPT Benefits

6. Manual revisions will clarify that SNF, HH, and OPT coverage of therapy to perform a maintenance program does not turn on the presence or absence of a beneficiary’s potential for improvement from the therapy, but rather on the beneficiary’s need for skilled care.
a. The manual revisions will clarify that, under the SNF, HH, and OPT maintenance coverage standards, skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (“skilled care”) are necessary for the performance of a safe and effective maintenance program. Such a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program. When, however, the individualized assessment does not demonstrate such a necessity for skilled care, including when the performance of a maintenance program does not require the skills of a therapist because it could safely and effectively be accomplished by the patient or with the assistance of non-therapists, including unskilled caregivers, such maintenance services will not be covered under the SNF, HH, or OPT benefits.

b. The manual revisions will further clarify that, under the standard set forth in the previous paragraph (Section IX.6.a.), skilled care is necessary for the performance of a safe and effective maintenance program only when (a) the particular patient’s special medical complications require the skills of a qualified therapist to perform a therapy service that would otherwise be considered non-skilled; or (b) the needed therapy procedures are of such complexity that the skills of a qualified therapist are required to perform the procedure.

c. The manual revisions will further clarify that, to the extent provided by regulation, the establishment or design of a maintenance program by a qualified therapist, the instruction of the beneficiary or appropriate caregiver by a qualified therapist regarding a maintenance program, and the necessary periodic reevaluations by a qualified therapist of the beneficiary and maintenance program are covered to the degree that the specialized knowledge and judgment of a qualified therapist are required.

d. The maintenance coverage standard for therapy as outlined in this section does not apply to therapy services provided in an inpatient rehabilitation facility (IRF) or a comprehensive outpatient rehabilitation facility (CORF).

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Here the link to the complete settlement agreement:

New York Times article:

9 comments to Proposed Settlement to Broaden Medicare Coverage for Chronic Conditions

  • Brianne Klingenberg

    Will this “skilled care” and/or “qualified therapist” finally include LMTs w CLT training ?

    • Joachim Zuther

      Dear Brianne: In response regarding reimbursement issues for LMT’s I would like to address the fact that it always was – and is – difficult for LMT’s to receive reimbursement from insurance companies and Medicare for services they provide. Some states and insurance companies reimburse services provided by LMT’s, others do not. This is the case for all services provided by Massage Therapists – Swedish Massage, Shiatsu, MLD, etc.
      In other words, attending and successfully completing a course in MLD/CDT will not change the reality that insurance companies usually do not accept claims provided by LMT’s.
      Most of the LMT’s that are trained and certified in lymphedema management work on a private pay basis, i.e. the patients are treated and provided with an invoice for the services rendered.

      As with all other continuing education
      programs for your profession, the basic facts in terms of reimbursement from health insurance carriers and Medicare remain unchanged.

      This does not mean that we all agree with these limitations, the opposite is the case. LMT’s were the first health care professionals in this country to provide lymphedema care and it is very unfortunate that these limitations exist.
      I light of this, it is unlikely that the proposed settlement will change the status quo.

  • Kevin Ribbel PT

    I have presently been involved in a MCR review for the continued use of 97140 for treatment. Since this time I have only been under full review and trying to conform to the upmost estringency of the local FL LCD codes. After continuous study of them and revision of my notes I have still continuously being denied and have no feedback regarding what is missing or wrong. I guess I have 2 questions is this new legislation going to affect this matter and also it is a warning for other certified LYmphedema therapists in Florida that this will eventually affect you. As the current statue reads you are only to be seeing patient’s for the purpose of education and that once they are able to take care of themselves they should be discharged. If the client is not capable of doing this or does not have the resources there is question if they are even able to be admitted questioning future re-imbursement for that therapy. Under the LCD the reasonable amount of time is 3-5x week 2, I implore you to address this. I have read the LYmphedema workshop from NLN and looked over the LCD or local carrier determination and still have had no luck and plenty of denial for lack of substantial documentation. There does not seem to be anyone able to review material or tell you what needs to be adjusted. My evaluation is now 6 pages long for each patient including a Lower Extremity or UE Functional assessment and requires 2 week additional re-assessments. I am still receiving denials. The only other solution appears to be to call a MCR consultant which is about 2 or 3 thousand dollars to review maybe 1/2 dozen charts.
    Is there any help for this situation? and if there is it should be made available to our profession.

    • Joachim Zuther

      Hello Kevin: This is a very complex issue and I urge you to contact Robert Weiss; as you may know, Bob is a Lymphedema Activist and knows pretty much everything about these issues. He is much better suited to comment and possibly assist you in this matter. You can contact him at

  • Kevin Ribbel PT

    thank you for your input. I know this is a very complex issue. I have contacted Bow Weiss and he has sent me the workshop regarding documentation. It just appears that it is not the full solution as of yet. I KNow that local florida Therapists going through the same issues. We are trying to share as much information as we can. I fear this may be the norm to come wtih MCR recoupment of lost MCR funds.

    Thank you for your time.


  • theresa

    i am a LPTA,CLT practicing lymphedema therapy for about 15 years. i am the lymphedema director of a home health agency here in florida right now all out pt clinics are 80% to 100% under reveiw right now reimbursement for med B is almost immposible and i know many end up closing (out pt clinics because they still need to continue seeing pts while under reveiw and being deniedpayment) i have heard medicare doesnt want mld billed by itself there is a modality that needs to be billed with it its either ther ex or gait and there is one modality billed with mld that if you bill together it red flags medicare to denie you need to speak to a billing specialist who deals only in mld through med b a medicare b billng specialist

  • Lori

    Wondering if nursing is going to be covered by Medicare in the near future? I am a nurse working in home health trying to set up a program within our agency. I hate to not see medicare pts .

  • shlomit Krienberg

    My Question is regarding Medicare Coverage for Chronic Conditions.
    Did Medicare broaden the coverage for chronic conditions following the article you published on October 25, 2012?
    The article mentioned that Medicare has at times denied coverage for skilled care for beneficiaries whose condition was not considered likely to improve.
    Please renew your sending all information you publish to me! For some reason you stoped sending me mail.
    Shlomit Krienberg