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Medicare carriers and intermediaries are permitted to develop
Local Coverage Determinations, also known as Local Medical
Review Policies (LMRPs), pertaining to Medicare coverage
of services and procedures. However, these LMRPs often restrict
coverage of services to individuals with Alzheimer’s
disease.
For example, coverage of mental health services is limited
by Medicare carriers’ policies that incorrectly assume
that individuals with Alzheimer’s cannot benefit from
psychiatric care. Many Medicare beneficiaries with Alzheimer’s
experience depression, agitation, personality changes and
other behavioral disturbances. Geriatric psychiatrists and
psychologists can provide behavior management, especially
for those with agitation, psychosis or aggressive behavior
and treatment of major depression.
Other Medicare carriers’ policies restrict access
to physical, occupational or speech therapies for beneficiaries
with Alzheimer’s, regardless of stage or functional
capacity. These policies fail to recognize the benefit of
occupational, physical and speech therapy to maximize functioning
for the individual with dementia. A growing number of research
studies substantiate the benefits of rehabilitation therapies
to slow deterioration for individuals with Alzheimer’s
disease.
The Alzheimer’s Association recommends that CMS adopt
Medicare coverage policies and regulations that promote
optimal care by:
Removing barriers to medically necessary care, such as inappropriate denials of mental health services and restrictions on rehabilitation therapies, for beneficiaries with Alzheimer's disease. Routinely re-evaluating LMRPs and developing new policies that are consistent with current clinical practices and standards for the diagnosis and treatment of individuals with Alzheimer's disease. Educating providers, beneficiaries and caregivers about the 2001 Program Memorandum, which prohibits the automatic denial of claims for medical services based solely on the diagnosis of dementia. Enforcing the 2003 Medicare Manual revision that expands the prohibition of computer software edits to automatically deny payment of services based solely on the diagnosis of a "progressively debilitating disease."
Next: Access Under Age 65
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A growing number of research studies substantiate the benefits of rehabilitation therapies to slow deterioration for individuals with Alzheimer’s disease.
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