Outdated Standard in Medicare Unfairly Denies Coverage

Medicare and its “Failure to Improve” Policy

For many seniors and their families, regular therapies, treatments, and checkups are all a part of maintaining good health. This is especially true for seniors suffering from chronic, progressive illnesses like dementia, diabetes, or heart disease. Daily or weekly medical interventions help them to live longer, happier lives. Yet an old, unofficial Medicare policy of denying coverage to patients who experience a “failure to improve” has caused a stir amongst seniors and their caregivers. Of course, regular treatments often do not improve seniors’ health, but they can help them live longer or stave off some symptoms. Many seniors will eventually fail to improve in health, but it is unfair to deny them coverage for medical care.


Medicare and its “Failure to Improve” Policy


For seniors affected only temporarily, this general rule of thumb can make some sense. Rather than endless therapies which will never bring them total recovery, seniors receive treatment until they reach a “plateau”. When a patient gets to this “plateau”, Medicare denies more coverage for further treatment, effectively discontinuing it. For example, a senior who has fallen and broken a hip may never recover the level of mobility enjoyed before the accident. Therapy set to improve the person’s functionality as much as possible, without additional procedures, makes sense. Transportation to and from doctor visits may also make treatment cessation or slow down a wise choice.

For other seniors, however, this is disastrous. In the case above, if a senior’s mobility improves but needs maintenance via physical therapy, denying coverage leads to one of two options. Either the senior and his or her family pay up front for the therapy (possibly leading to astronomical bills) or therapy is skipped. Then the senior’s health and well-being decline. Additionally, in such a case, the senior risks losing functionality and independence. This may lead to feelings of loneliness and isolation, which increase the risks of depression or anxiety.

Some therapies help manage chronic pain. These types of therapies go on for as long as possible to help improve a patient’s quality of life. Losing control of chronic pain increases the risk of the above-named side effects. It drastically raises the risk for suicide attempts among seniors, a deadly potential consequence of outdated red tape.


History of the Term


Medicare used to employ the term “failure to improve” in pamphlets and information disseminated for providers and Medicare adjudicators. It never actually made an appearance as official law or regulation. However, it was still generally a part of Medicare practice until 2013. Essentially, if providers could not show that a given treatment or therapy improved the health of a patient, Medicare would not cover it any longer. A 2013 ruling on the case sided with seniors and their advocates. The ruling states that treatment or therapies which help to maintain the health of the patient can be covered by Medicare. Since this ruling, seniors, people with disabilities, and their advocates have pushed for more education for providers around this issue.

Despite the ruling, many seniors still receive notices of coverage denial due to outdated Medicare policies. This means that seniors may be denied coverage and have to suspend treatment or pay for it out-of-pocket.


What This Means for Family Caregivers


If an elderly loved one has received notification that Medicare will not pay for treatment due to “failure to improve,” it is important to appeal it immediately. The source of the documentation should be informed that this is no longer a valid reason to deny coverage. If, for some reason, the elderly person’s health care provider no longer believes their services are necessary to maintain the person’s  health, a second opinion is called for. This will begin the appeals process for Medicare’s coverage.

Unfortunately, this process typically ends badly for those seeking to overturn judgments or receive reimbursements for care they paid for out-of-pocket. However, these formal processes can work out, especially if initiated promptly.



Deford, Gill, Murphy, Margaret, and Stein, Judith. (January-February 2010). How the ‘Improvement Standard’ Improperly Denies Coverage to Medicare Patients with Chronic Conditions. Center for Medicare Advocacy. Clearinghouse Review, 43(9-10). Available at http://www.medicareadvocacy.org/how-the-improvement-standard-improperly-denies-coverage-to-medicare-patients-with-chronic-conditions-%E2%80%93-text-of-article-printed-in-clearinghouse-review-vol-43-no-9-10-jan-feb-2010/. Retrieved September 25, 2016.

Ku, Leighton, MacTaggart, Patricia, Pervez, Fouad and Rosenbaum, Sara. (July 2009). Improving Medicaid’s Continuity of Coverage and Quality of Care. George Washington University Department of Healthy Policy for the Association for Community Affiliated Plans. Available at http://www.communityplans.net/Portals/0/ACAP%20Docs/ACAP%20MCQA%20Report.pdf. Retrieved September 25, 2016.

Span, Paula. (September 12, 2016). Failure to Improve Is Still Being Used, Wrongly, to Deny Medicare Coverage. The New York Times. Available at http://www.nytimes.com/2016/09/13/health/medicare-coverage-denial-improvement.html?_r=0. Retrieved September 25, 2016.