Question and Answer

I have Alzheimer's disease and Medicare has been refusing to pay for my care. Is there anything I can do?

Question: 
I have Alzheimer's disease and Medicare has been refusing to pay for my care. Is there anything I can do?

Answer:
Yes, you should appeal. In 2001, Medicare notified the companies that process Medicare claims (regional carriers and intermediaries) that they should not make blanket denials of coverage of medical services for people with Alzheimer's disease or dementia. They should determine coverage for these services as they do for everyone with Medicare -based on the medical necessity. However, you may still experience inappropriate denials of treatment. Below are three situations in particular to watch out for:

  1. Denials of Physical, Speech and Occupational Therapy

    Especially in the early stages of Alzheimer's disease, skilled physical, speech and occupational therapy may be appropriate if it will help prevent or minimize any deterioration of your capabilities.

    If your doctor thinks that therapy can help you, Medicare should not refuse to pay based solely on a diagnosis of dementia or Alzheimer's disease, or on the rationale that your condition cannot improve.

  2. Denials of Mental Health Treatment

    People with Alzheimer's disease and dementia often suffer from related mental health conditions, such as depression and agitation. These conditions can be helped with treatments like psychotherapy and behavior management but you may be inappropriately denied coverage for these treatments if you have Alzheimer's or dementia.

    However, if your doctor thinks you can benefit from psychiatric or mental health services, Medicare should not deny your claim for these services based solely on your diagnosis of dementia or Alzheimer's disease and under the assumption that you will not benefit from the treatment. In addition, family counseling should be covered when it is needed to help your loved ones learn how to manage your condition.

  3. Incorrect Billing for Medicare Services

    Medicare uses treatment and diagnosis codes to process medical claims. Medicare may incorrectly deny or reduce payment for medically-necessary services if your doctor has submitted a claim to Medicare with the wrong codes.

    • If you received care for a condition unrelated to your dementia or Alzheimer's disease, like a broken hip, your doctor should submit a claim with a primary diagnosis code for that condition. If your doctor submits a claim with a primary diagnosis code of dementia or Alzheimer's, Medicare may deny any medical claims for the care you received. If you had hip replacement surgery, your doctor should use the proper hip replacement code as a primary diagnosis, not the diagnosis code for dementia or Alzheimer's disease.

    • Medicare generally pays 80 percent for a covered medical service including mental health services.

If your doctor has submitted an incorrect diagnosis or treatment code, you should ask your doctor to resubmit your claim with the correct codes. You may also need to appeal Medicare's decision.

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