Home Again

I am home now. In the last post that I wrote concerning my insurance situation, I was waiting to hear about my first insurance appeal for this particular stay in a skilled nursing rehab facility. It was good news when this first appeal was approved, and I was allowed to remain there a few more days.

There were more appeals to come, however. I was soon given another Notice of Medicare Non-Coverage listing December 9, 2022, as the last day covered by insurance. On December 10, if I were to remain in the facility, my husband and I would be financially liable for room and board while Medicare Part B would cover the costs of my therapy. Thus I filed another first round appeal and promptly lost.

About this same time, my right knee was really hurting. I was on a combination of hydrocodone, Tylenol, and Ibuprofen for pain. I sometimes awoke in the middle of the night and had to request pain medication and repositioning by the nurse or CNA for pain relief. My pain ranged at best in the 4 level all the way up to 8 to 10. It was not constant but was definitely present whenever my knee would be in certain positions or move in specific ways. The pain was frequent enough to be disruptive. Neither my therapist nor I know exactly what caused this setback, but the pain was usually the sharp, stabbing kind and not the achy, stiff joint kind. In other words, it felt like my old torn meniscus injury and less like the typical bone-grinding arthritis that I also have in my right and left knees.

I had torn the meniscus in my right knee back in February 2022 while I was doing physical therapy at another rehab facility following my January stroke. X-rays were taken back then but they failed to show anything other than the arthritis. It took the MRI completed at the hospital in April 2022 to show the torn meniscus injury. I had requested an earlier MRI but was turned down by the orthopedic doctor who told me that I wasn’t a good candidate for knee surgery. Finally in April I convinced the hospital doctor to do a knee MRI. This coming January (January 6, 2023), I am currently scheduled to have another MRI of my right knee. I want to know if it will show even more damage.

EDIT for UPDATE: The imaging center postponed my January MRI appointment until February 2023. I had the second MRI, which showed very similar damage to the first one, plus some additional change which would seem consistent with my fall out of my bed in November 2022.

This setback definitely impacted my physical therapy. Immediately prior to this setback I had 2 walks in physical therapy of 50 and 70 feet each, totaling 120 together. At the time my really bad knee pain began and just afterward, I could barely walk. Before the setback, my therapist told me I was a moderate to high risk for falls. When he did one of the tests in his Medicare Part B evaluation of me after my knee worsened, he said I was now a high risk for falls. After the pain had become bad enough that it was affecting my transfers, walking, and bed mobility, I immediately asked for and saw the facility’s nurse practitioner, who prescribed for me a 10-day course of prednisone to help take care of the inflammation. At this time, even though I am now home, I am still weaning off this prednisone. My knee pain continues also. On the day I saw the nurse practitioner, I rested in bed and stayed off the knee as much as possible. For my next two sessions, my physical therapist did not have me do any walking or spend any time on the NuStep bike. Instead we did leg exercises to strengthen the muscles around the knee. We also did some brief stands. Gradually I was able to do more walking and get back on the NuStep machine. Both my therapists were cautious about doing too much too soon. They did not want to risk re-injury to this knee.

Then the weekend came, and I was not scheduled for therapy for three days. Two of those days fell on the weekend, and the third day (Monday) was not scheduled because my therapy costs were being transferred to Medicare Part B since I was under appeal. In this facility you have therapy 10 times per week (5 PT sessions and 5 OT sessions). This means that you do not necessarily have therapy every day. That Monday (December 12, 2022) also was when I filed my second level (reconsideration) appeal. If my husband and I lost this appeal we would have to go private pay starting on December 10, 2022.

I had been very hopeful that the second appeal would be successful since my setback had been very carefully documented. That was not the case though, and I found out that my reconsideration appeal was denied just yesterday.

On my final of therapy, Friday, December 16, 2022, I was continuing to make progress. In OT, I did 15 minutes going forward on the arm bike at level 2 ( up from level 1) and 6 minutes going backward at level 2. Prior to this rehab stay I had always used the arm bike on pedaling forward. Pedaling backward was new for me. At first going backward seemed very awkward to me. I told my therapist though after my final 2 OT sessions that I could feel that my backward pedaling had become smoother.

Although this final OT day did not include any additional exercises, my OT usually had exercises for my arms and/or to strengthen my core. We used not only the arm bike, but also weighted dowels, flex bars, dumbbell weights, a ball rebounder, and a weight machine like you find in a fitness center gym.

My final PT sessions also demonstrated progress. On my last of PT, December 16, my therapist had me do more leg exercises for strengthening while sitting in my wheelchair. I also did wheelchair push-ups. I completed a 77 foot walk (my best ever distance for this rehab stay). Then I completed 15 minutes on the NuStep machine at level 3 (up from level 1) with 70 steps per minute. For anyone who doesn’t know about NuStep, it is a recumbent trainer machine that can exercise both your arms and legs. It is also easier on one’s knee joints than some other types of exercise machines. After the NuStep, I was very winded. That is one reason my therapist encouraged me to use it because it will also give you a good cardio workout. My goal had always been not only to gain muscle strength but also endurance.

My health record contains my diagnosis for heart failure. The day before my final PT treatment, I asked my therapist if exercise was good for heart failure. He said it was, but it needed to be done within certain bounds. It needed to be monitored. Being in the skilled nursing facility was certainly a plus for the heart failure since I had ready access to all the skilled professionals I needed — therapists, a doctor, nurse practitioner, and nurses. I could be monitored if need be 24/7. I experienced some periods when my blood pressure would would either spike or drop or when my heart rate would be higher than normal. At least three occasions my blood pressure dropped about 30 points following exercise. The blood pressure drop surprised my therapist, who checked my pressure three times and also had a nurse re-check it. I also experienced some “roaring” in my ears during two exercise periods. It was good to know that a nurse was there quickly to check me out.

After my walk, I asked my physical therapist if I had met the goal he had set for me. He said “no” — that his goal had been 100 feet or more. However, he explained that when he formulated his goal, he thought that I would be in the facility for at least another week. He told me that if I had been allowed by the insurance company to stay that time that I would have met the goal.

I believe that the insurance company and the qualified improvement organization should have approved my reconsideration (2nd level) appeal. I was beginning to make more progress and crawl out of the “hole” caused by my right knee setback. My walking distance was increasing, which is very important in our home. I cannot depend upon navigating our home with my wheelchair. Even my transport chair, which is narrower than my regular wheelchair, will not fit through all the doorways in our modular house. In other rooms, it is a very tight fit. Therefore I must be able to walk a certain number of feet to be able to get to the bathroom, the kitchen, bedroom, and living room, the areas where I spend most of my time. In the case of a fire, I need to be able to walk at least 108 feet in order to get safely out of the house. The distance to the front door is less, but there are 8 steps out front (includes one threshold) until you can reach the driveway. There is a handrail on only one side of the steps. When you reach the driveway, you step from a flat concrete surface to a gravel drive that slightly slopes downward from right to left. This was always a tricky step for me, even when I was stronger and in better condition. The side of the house has an exit with a wooden ramp that goes out into our backyard. Our home is wooden; it would be necessary for me to go some feet beyond the end of the ramp to be safe from any fire. As I mentioned earlier, this minimum distance is 108 feet.

I really needed to stay this additional time so that I could get even stronger and truly be safe at home, but unfortunately we could not financially afford these extra days.

My husband and I plan to file a 3rd level appeal with the administrative law judge. We have 60 days to fill out the appropriate form. Then we wait to be given a hearing date, and we put together our case. In the meantime, rather than accrue thousands of dollars of more debt, I came home today. (See below for UPDATE. We filed the appeal and won.)

I am feeling positive though because (1) I think that due to the setback and the progress that I was able to make until the present that we have a good appeal case, and (2) I will be getting more support here at home.

It is not that late yet tonight, but as soon as I finish supper, I will be going to bed. I am tired after leaving the rehab and my friends there earlier today.

Sometime this next week, I will be adding a section to this website about some of my experiences in and advice concerning rehab facilities and Medicare Advantage insurance appeals. I will likely put these pages under a separate link. I hope that people may find this information helpful.

Blessings to all and goodnight! It is almost Christmas and 2023!

EDIT for UPDATE: My husband and I filed a 3rd level Medicare Advantage appeal. We had the hearing before the Administrative Law Judge on April 13, 2023. After a few days of deliberation, she decided the appeal completely in our favor. This means that the insurance company will now have to pay for the final week of rehab that was paid privately by us. You have a significantly improved chance of winning an appeal at the 3rd or upper level than you do at levels 1 or 2. It is worth fighting back.