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Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
Medicare will pay for services that are reasonable and medically necessary for the diagnosis or treatment of a 
condition, illness or injury in the beneficiary.  (Section 1862 (a)(1)(A) of the Social Security Act).  When an 
appellant requests a reconsideration, all documentation to support the services being appealed must be included 
with the request for reconsideration.  The provider is responsible for providing sufficient documentation to 
support that payment is due and the services were medically necessary and provided as billed. You can find this 
rule in the 42 Code of Federal Regulations Section 424.5(a)(6). 
 
A comprehensive outpatient rehabilitation facility (CORF) is established and operated exclusively for the 
purpose of providing diagnostic, therapeutic, and restorative services to outpatients for the rehabilitation of 
injured, disabled, or sick persons, at a single fixed location, by or under the supervision of a physician.  For 
each beneficiary, a physician must establish and sign a plan of treatment before the facility initiates treatment. 
The plan of treatment must meet the following requirements:   
 
1)         It must delineate anticipated goals and specify the type, amount, frequency and duration of services to 
be provided.  
2)         It must be promptly evaluated after changes in the patient's condition and revised when necessary. 
3)         It must, if appropriate, be developed in consultation with the facility physician and the appropriate 
facility professional personnel. 
4)         It must be reviewed at least every 60 days by a facility physician who, when appropriate, consults with 
the professional personnel providing services. The results of this review must be communicated to the patient's 
referring physician for concurrence before treatment is continued or discontinued. 
5)         It must be revised if the comprehensive reassessment of the patient's status or the results of the patient 
case review conference indicate the need for revision. 
 
You can find this rule in the 42 Code of Federal Regulations Sections 410.105, 485.51, 485.58. 
 
The plan must be reviewed at least every 60 days for respiratory therapy services and every 90 days for 
physical therapy, occupational therapy and speech-language pathology services by a facility physician or the 
referring physician who, when appropriate, consults with the professional personnel providing the services. 
You can find this rule in the Medicare Benefit Policy Manual, Chapter 12, Sections 10, 30(E). 
 
Medicare requires that the plan of treatment must be reviewed at least every 60 days for respiratory therapy 
services and every 90 days for physical therapy, occupational therapy and speech-language pathology services 
by a facility physician or the referring physician who, when appropriate, consults with the professional 
personnel providing the services.  The reviewing physician must certify or recertify that the plan is being 
followed, the patient is making progress in attaining the rehabilitation goals, and the treatment is having no 
harmful effects on the patient. You can find this rule in the 42 Code of Federal Regulations, Section 410.105 
and the Medicare Benefit Policy Manual, Chapter 12, Section 30(E). 
 
A CORF must provide physicians? services, physical therapy services and social and/or psychological services.  
A CORF may also provide optional services such as occupational therapy, speech-language pathology, and 
respiratory therapy.  When a CORF provides these optional services, in addition to the required physical 
therapy services, the physical therapy services must represent the predominate rehabilitation service provided.  
If physical therapy services are not the predominate rehabilitation service provided, the optional services do not 
meet Medicare criteria for coverage. You can find this rule in the Medicare Benefit Policy Manual, Chapter 12, 
Sections 20.1, 20.2, 40.3, and 40.4. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.