Medicare Denied Claim: Not Improving (Maintenance)

What This Means

Medicare reviewed your claim and determined that the services were no longer necessary because your condition was not improving. This type of denial is common for physical therapy, occupational therapy, speech-language pathology, and skilled nursing facility care.

Here is the important part: Medicare is not supposed to deny coverage just because you are not improving. A landmark legal settlement – Jimmo v. Sebelius (2013) – confirmed that Medicare must cover skilled care that is needed to maintain your current condition or prevent further decline, even if improvement is not expected.

If your denial is based on a lack of improvement, you may have strong grounds to appeal.

Why This Happens

• The “improvement standard” is still being applied. Despite the Jimmo settlement, some Medicare reviewers and automated systems continue to deny claims because the patient is not showing measurable improvement. The Center for Medicare Advocacy has documented this as an ongoing problem.
• The documentation did not explain the need for skilled care. Even when therapy is needed to maintain function, the therapist must document why skilled care (not just general exercise or routine caregiving) is required. If the notes are not detailed enough, the claim may be denied.
• The therapy goals were not clearly stated. Medicare expects documentation that includes specific, measurable goals – even for maintenance therapy. Goals like “maintain current range of motion” or “prevent falls through balance training” are valid, but they need to be clearly documented.
• A Medicare Advantage plan applied its own criteria. Some MA plans use clinical guidelines that may not fully reflect the Jimmo settlement’s requirements. These denials can often be overturned on appeal.

Should You Appeal?

What To Do Next

1. Look for improvement-based language in your denial. If the denial mentions phrases like “not improving,” “no further progress,” “reached maximum potential,” or “plateau,” this may be an improper application of the improvement standard.
2. Ask your therapist for a detailed letter. The letter should explain why skilled care is needed to maintain your condition or prevent decline, describe the specific skills required (that a non-professional could not safely provide), and reference the Jimmo v. Sebelius settlement.
3. Reference the Jimmo settlement in your appeal. Cite the Jimmo v. Sebelius settlement agreement (2013) and CMS’s revised Medicare Benefit Policy Manual, which states that coverage is not dependent on a patient’s potential for improvement.
4. Contact the Center for Medicare Advocacy. They offer a free self-help packet for outpatient therapy denials that includes sample appeal language specifically for improvement-standard denials.
5. File your appeal promptly. Include your denial notice, your provider’s letter, relevant therapy notes showing skilled care was provided, and a reference to the Jimmo settlement.

Sources

• CMS: Jimmo v. Sebelius Settlement
• CMS: Jimmo Settlement FAQs
• Center for Medicare Advocacy: Improvement Standard and Jimmo News
• Center for Medicare Advocacy: Self-Help Packet for Outpatient Therapy Denials
• Medicare.gov: Your Medicare Rights & Appeals

Frequently Asked Questions