News & Events

Story of Justice: Betsy*

Recently, CCLA attorneys were able to assist Betsy* with obtaining Medicare benefits. Betsy was diagnosed with anterolisthesis, which causes severe pain and rendered her unable to move. She also was diagnosed with pulmonary embolism and has an otherwise very complex medical history.

Betsy was hospitalized three times in late 2017 and early 2018 for the back condition. She stayed at home for one week between hospitalizations, but due to the inadequate care and facilities, her condition worsened. After her third hospitalization, she was admitted to a skilled nursing facility (SNF) for rehabilitation. After three weeks in the SNF facility, Betsy’s condition improved greatly and she was released.

Unfortunately, Betsy received a bill for $12,000 from the facility. Her Medicare plan claimed that the inpatient care was not necessary and denied the preauthorization request after she had been at the SNF for two weeks.

With CCLA’s assistance, Betsy requested a hearing to appeal this decision. CCLA attorneys submitted a nine page brief and over 600 pages of medical records to the Office of Medicare Hearings and Appeals on Betsy’s behalf. This documentation showed that the Medicare Advantage plan included coverage for the SNF stay.

Although representatives for the Medicare plan failed to appear for the video hearing, Betsy and her CCLA attorney were able to present her case. The plan representatives were allowed to submit a written response after the hearing. Regardless, the Administrative Law Judge found that the Betsy met the Medicare requirements for inpatient SNF care and her Medicare plan subsequently paid the invoices.

*Names have been changed to protect the privacy of our clients.