Brown v. Shalala

No. 94-CV-10542-JLT (D. Mass. Aug. 8, 1995). ; Clearinghouse Number: 50957

Description

Claimant Using Day Passes While Hospitalized Is Entitled to Medicare Coverage for Inpatient Psychiatric Care

Abstract

The district court has reversed defendant Secretary of HHS’s denial of Medicare coverage to plaintiff for inpatient psychiatric care. When admitted to the hospital with a diagnosis of paranoid schizophrenia, plaintiff was grossly psychotic and delusional, in part because she had stopped taking her medication. While hospitalized, plaintiff underwent drug, group, individual, and milieu therapy. Although plaintiff’s treating physician concurred with the hospital’s decision to terminate Medicare coverage on September 15, 1989, plaintiff was not discharged until 12 days later. Finding that plaintiff had not been receiving "active treatment" during the period in question, defendant denied plaintiff’s claim for Medicare reimbursement. On appeal, the district court found that defendant did not address specifically how the services plaintiff received failed to satisfy the criteria for active treatment. The court noted that, although plaintiff’s condition improved greatly once she resumed taking her medication, her condition fluctuated throughout her hospitalization. Rejecting the argument that plaintiff’s use of day passes indicated that her hospitalization was no longer necessary, the court found that adjunctive therapies, such as milieu therapy, which included the use of day passes, could be properly considered active treatment as long as they were reasonably expected to improve the patient’s condition. The court also rejected defendant’s argument that plaintiff’s active treatment had ceased because neither her medication nor her treatment plan changed substantially after September 15. Finding that active treatment did not cease merely because a patient’s medication was stable, the court held that plaintiff was still receiving active treatment on September 15 and was entitled to Medicare coverage for the remainder of her hospitalization.

Additional Information

Attorney Information
Plaintiff/Claimant represented by Karen Dobak (paralegal), Lynne Berry, Medicare Advocacy Project, 197 Friend St., Boston, MA 02114, (617) 371-1234.
Docket Date
1995-08-08 00:00:00+00:00