MEDICARE FAIR HEARING SAMPLE LETTER

Name:  Susie Resident

Medicare Number: 123-45-6789 A

Dates:  01/31/02 through 01/21/02

This Resident was a 101 year old female with a medical diagnosis of cerebral vascular accident onset of 10/04/01 with secondary diagnosis of dysphagia and dysarthria.  She was referred to us by her physician, Dr. Paul Feelbetter, for a speech/swallow evaluation.  Reported concerns from staff and family included:  slurred speech, poor vocal quality, weight loss due to reduced oral intake, and the need to determine if Ms. Resident was safe for a possible upgrade in diet texture.  Ms. Resident’s daughter and nursing staff had indicated increased difficulty for Ms. Resident at mealtime, coughing and choking were demonstrated, and weight loss concerns were expressed.

Following a thorough screening, it was determined that ­Ms. Nutrition, the registered dietician for Happy Days Manor, had indicated on 1/16/02 that a 2-5 lb. weight loss had been experienced over the last 2-4 weeks for Ms. Resident.  This weight loss concern was expressed to Dr. Feelbetter on 1/17/02.  Dr. Feelbetter had met with Ms. Resident on 1/17/02, staff had notified Ms. Resident’ daughter on 1/18/02 of her weight loss.  On 1/19/02, Dr. Feelbetter acknowledged this weight loss and would address that concern at rounds.  On 1/20/02, Dr. Feelbetter was again in the facility examining Ms. Resident.  Speech pathology had screened Ms. Resident on 1/27/02 and determined she could reasonably expect to benefit from an evaluation and direct speech therapy.  She demonstrated the ability to manage liquids that were of a thinner of consistency than honey.  She demonstrated self feeding skills, her communication skills were poor, and she was having difficulty expressing to staff her needs at mealtime.  Compensatory strategies introduced aided in increasing oral intake. 

With this information in hand, it was determined that a speech/swallow evaluation was in order.  A risk for continued weight loss was evident and poor communication skills placed her at risk for not having her medical needs and wants and safety issues expressed completely.  She was also at risk for aspiration.  An expectation that this condition would improve significantly with skilled speech-language pathology services was apparent.  Following consultation with her medical staff, it was determined to proceed with the evaluation. 

MEDICARE REPORT 504/3910, Letter A, Page 5.91, Titled “Medical Work-up” indicates:

The physician may work in collaboration with the Speech-Language Pathologist to assess for dysphagia risk.

Dr. Feelbetter ordered the assessment.  He examined Ms. Resident on 1/17 and 1/20/02.  He ordered the evaluation due to the presence of dysphagia and the risk for aspiration.

MEDICARE REPORT 504/3910, Letter B states:

The diagnosis of dysphagia requires the risk for aspiration to be present, or a swallow reflex delay, pocketing, loss of bolus management, sensation loss, no chewing, or a risk for weight loss. 

Some of these were determined to be present following the screen and evaluation.  On 1/29/02, Ms. Resident was assessed using clinical and professional observations to determine current skill levels for safe swallow skills and speech production.  She demonstrated drooping of the oral musculature on both sides.  Reverse swallow behaviors were noted occasionally.  She was chewing with an open mouth and rotary jaw movement was limited.  She was not able to clear the oral cavity completely with each swallow.  Wet voicing occurred occasionally following swallows of liquid.  Aspiration behaviors were noted due to:  talking with her mouth full, chewing with an open mouth, washing down food with liquids, and limited rotary jaw movement.  Ms. Resident had demonstrated improved alert levels and requested thinner liquids.  Clinical impressions were observed as moderate oral swallowing and speech production impairments.  Safe swallow guidelines were discussed with staff and Ms. Resident.

Our assessment met the Medicare requirement for assessments, MEDICARE REPORT 504/3910, Page 5.91, Letter D, requiring the identification for paralysis, choking and coughing, an oral motor assessment, oral sensitivity, muscle tone, cognition, positioning, laryngeal function, swallow reflex, and swallow function.

Aspiration behaviors were noted.  Clinical impressions suggested a moderate swallowing and speech production impairment.  It was recommended that Ms. Resident begin a trial period of mechanical adjusted texture during direct speech therapy sessions only and should be given pureed texture with nectar consistency liquids at mealtime.  Prognosis for attaining goals is good due to Ms. Resident’s motivation and ability to learn from repetition and cueing and family support.  She was alert and able to swallow small amounts of food and liquid, suggesting treatment to improve swallow consistency and oral intake would be effective.

Functional goals and objectives for Ms. Resident included completing activities specific to dietary, postural and therapeutic skills as tolerated, safely managing oral intake to meet nutritional needs, thermal stimulation activities to improve anterior to posterior control and movement, and oral motor exercises to improve speech production and vocal quality in conversations. Our plan of treatment focused on improving speech production and increasing safe swallow skills and texture tolerance. 

Our care plan met the Medicare requirement for care plan MEDICARE REPORT 504/3910, Page 5.931, Letter E.

We determined the need for caregiver training, established proper safe positioning, safest bite-size, appropriate diet texture, presented means to facilitate a safe swallow, introduced feeding techniques, oral facilitation techniques, and oral sensitivity training. 

While enrolled in direct speech therapy during the month of February, Ms. Resident was seen 3 time's per week with treatment focusing on improving vocal quality and increasing safe swallow skills and texture tolerance.  She had demonstrated noticeable improvement as a result of treatment.  At the beginning of the billing period, Ms. Resident’ vocal quality was approximately 50% intelligible in sentences.  Oral exercises were conducted to strengthen oral musculature.  Ms. Resident finished the month repeating 6-7 words in length with 90% intelligibility.  Conversational intelligibility was up to 75%.  At the beginning of the billing period, Ms. Resident was on a puree diet texture with nectar liquids.  She had progressed to a mechanical soft diet with nectar thickened liquids.  Trails of thin liquids were given with instructions for chin tuck protective swallow strategies.  This resulted in no coughing after swallows were implemented.  Direct speech therapy was recommended to continue to ensure safety and carry over of skills. 

MEDICARE REPORT 504/3910, Page 594, Letter J, Titled “Safety” states:

Documentation must indicate appropriate treatment goals to improve patient’s swallow function and must also indicate that the treatment was designed to ensure that it is safe for the patient to swallow during oral feedings and that improving the patient’s safety and the quality of their life with improved nutritional intake would be a primary emphasis in treatment goals.

We believe that was clearly our intent for continuing services into the month of March 2002.

During March of 2002, Ms. Resident continued to receive direct speech/swallowing therapy emphasizing increased safe swallow skills and texture tolerance.  During the month of March 1902, Ms. Resident’ physical endurance and wellness decreased due to an eye infection.  Therefore, Ms. Resident was placed on “hold” for 1 week.  We met the MEDICARE REPORT 544, Page 5-26.28, Letter D guidelines because we hoped that she would either become more alert, attentive or cooperative, show improved rehab potential, and her medical complication cleared.

When Ms. Resident’s health did improve, direct speech therapy continued.  Having met her speech production goal during the month of February, focus in March was placed on safe swallowing.  At discharge, Ms. Resident was managing mechanical soft diet texture (up from puree), independently alternating textures at discharge, compared with requiring maximum cues at the beginning of treatment.  Oral intake has increased overall after the upgrade in diet and continue when she recovered from her illness.  Ms. Resident stopped losing weight.  She was managing nectar consistency liquids without difficulty and monitoring appropriate bite-size.  Trial periods of thin liquid were attempted, however, Ms. Resident coughed occasionally after drinks of thin liquids with a possible swallow reflex delay evident.  Thermal stimulation and oral motor exercises were attempted with limited success and Ms. Resident was unable to consistently use the chin tuck strategy to increase safety of swallow with thin liquids. 

We believe that her success in direct speech therapy met MEDICARE HANDOUT 543/502, Page 5.54 defining “significant” as substantial increases in the patient’s present level and competence compared to when treatment was initiated. 

We believe that improving Ms. Resident’ speech production skills to independently carry out communicative abilities with daily living and improving safe swallow skills to a higher level of attainment prior to the initiation of service would be considered significant. 

In the same handout, one is warned not to interpret significant too stringently and to not continue simply because of a temporary set back in a patient’s progress.  We believe this section provides justification for continuing to provide speech therapy after having placed Ms. Resident on hold.

We believe that Ms. Resident’ services reasonably expected to gain her as much independence as possible while living at Happy Days Manor.   Medical charted indicates Dr. Feelbetter was in the facility to see Ms. Resident on 2/21/02.  On 3/12/02, charting indicates weight was stable.  On 3/20/02, Dr. Feelbetter was in the facility to see Ms. Resident and physician report indicated, “improved communication, alert, stable, doing better” and on 3/28/02; Ms. Resident was alert and answering questions readily.  On 2/28/02, the Activities director indicated in her charting that Ms. Resident was attending activities consistently and had attended chapel 8 times, memory lane 2 times, had been to 4 special parties, she had received one-on-one visits, participating in group sensory, and been to Chatterbox Café 13 times.  She had indicated Ms. Resident had requested her goals remain the same for the following month.  She was a remarkable 101 year old person.  She and her family’s needs to communicate well and remain independent were clearly a consideration in continuing direct speech therapy.  She was exceptionally alert and aware, her deficits made improving communication skills important.

MEDICARE REPORT 504/3910, Page 5-26.25, #5, Titled “Level of Complexity” requires: The analysis of a speech-language pathologist for therapy to make the activity skilled. 

We believe we’ve clearly demonstrated that to be the case.

Ms. Resident was discharged immediately from direct speech therapy when it was determined that her rehab potential had been met and that her skills were not going to increase significantly.  The services provided were reasonable and necessary to the treatment of Ms. Resident’ deficits so as to improve functions necessary to daily living and to help her family and staff improve the quality of their relationship.

Sincerely, 

Certified Speech Language Pathologist