Appeal type: unknown
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. 
 
The rules say that physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services are 
covered only when they are medically reasonable and necessary. Therapy services are considered reasonable 
and necessary when: 
 
1. The services are specific and effective treatment for the patient's condition, 
 
2. The services require the skills or direct supervision of a therapist,  
 
3. The amount, frequency, and duration of the services is reasonable under accepted standards of practice, and   
 
4. The services are needed to address recovery of or improvement in function OR to establish, design, deliver, 
or carry out a maintenance program.  
 
Medicare coverage is based not on a patient's potential for improvement, but rather on the patient's need for 
skilled care. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.2. 
 
The rules also say that services must be under accepted standards of medical practice and considered to be 
specific and effective treatment for the patients condition. The amount, frequency, and duration of the services 
planned and provided must be reasonable. Services must be necessary for treatment of the patients condition: 
The medical record must clearly describe the patients condition before, during, and after the therapy episode to 
support that the patient significantly benefited from ongoing therapy services and that the progress was 
sustainable and of practical value when measured against the patients condition at the start of treatment. 
Documentation of comparable objective/functional measures plays a key role in demonstrating medical 
necessity. 
 
Medicare reimburses for the development of a medically necessary individualized maintenance program to: 
1. Maximize and retain the patient's functional status achieved with therapy services; 2. Assure patient safety within their home environment; 
3. Train the patient and/or caregiver in the maintenance activities; 
4. Prevent further decline in the patient's condition. 
Medicare does not reimburse for carrying out maintenance activities when: 
1. The activities do not require the skills of a qualified clinician i.e., the level of complexity and 
sophistication of the activities do not require the performance and/or supervision of a therapist. 
2. The condition of the patient is such that the services do not require the performance and/or supervision 
of a therapist. 
3. The activities can reasonably be provided by non-skilled personnel after training is completed by the 
qualified clinician. 
It is anticipated that once the maintenance program is established, updates to the program will be necessary on 
an infrequent basis. 
When additional medical necessary services are required for the same medical condition, a thorough initial 
evaluation should be completed for the patient who was previously discharged. Documentation for 
maintenance program revisions must support that any additional therapy services require the performance 
and/or supervision of a qualified therapist due to the complexity/sophistication of the required procedures 
and/or the condition of the patient. The documentation must clearly indicate why a revision of the maintenance 
program is necessary and what specific revision(s) are needed.  
You can find these rules in the Local Coverage Article Billing and Coding: Medical Necessity of Therapy 
Services, A55304. 
 
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.