Major Changes in Physical Therapy Coverage for Individuals with Duchenne and Becker

Obtaining physical therapy (PT) services for individuals with Duchenne and Becker muscular dystrophy, and other conditions for which PT does not result in improvements in range of motion or function, has been a huge source of frustration for patients, parents, and providers.

A recent decision involving the Centers for Medicare and Medicaid (CMS) and addressing coverage for PT services directed at maintaining function and range of motion, rather than improving them, should make this a smoother process. 

 

What Was the Issue?

In fall 2001, six families and seven national organizations filed a complaint with their district court, around the issue of whether the CMS have the right to operate according to the “Improvement Standard,” thus denying reimbursement or terminate services for beneficiaries who are not “improving.”

In October 2011, a settlement agreement between the plaintiffs and Health and Human Services secretary, Kathleen Sebelius, was proposed. The district court judge approved this agreement in November 2012; the CMS have until January 2014 to institute changes and education agreed to in the settlement. 

 

What Does This Mean to You?

In short, this decision may have a significant impact on decisions made by the CMS regarding coverage for skilled PT and care in the areas of home health, outpatient therapy and extended care (i.e., nursing home care). 

Changes will include:

  • Inclusion of a “maintenance coverage” standard in the Medicare Benefits Policy Manual
  • National education explaining the clarified benefit to contractors, providers and beneficiaries

 

According to President Paul A. Rockar, the American Physical Therapy Association (APTA):

“APTA has long believed that every patient has the right to receive medically necessary physical therapist services regardless of diagnosis, condition, or illness. The ability to improve should never be the sole determining factor in deciding whether or not a patient receives the skilled services of a physical therapist.” 

The APTA has vowed to work closely with CMS, providing clinical and professional expertise as they work to define appropriate treatment, and to ensure that patients are not unfairly denied medically necessary physical therapy services. They are also working to educate PT providers regarding appropriate care according to this settlement.

 

Read the Settlement Agreement Fact Sheet

 

Additional Background

CMS.gov: Therapy Services

APTA.org: Statement by APTA

AOTA.org

Center for Medicare Advocacy

Kaiser Health News

 

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