evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
If the use of a care alternative involves transportation of the individual on a daily basis, the A/B MAC (A) considers whether daily transportation would cause excessive physical hardship.  Determinations on whether a patients condition would be adversely affected if an available, more economical care alternative were utilized should not be based solely on the fact that the patient is nonambulatory.  There are individuals confined to wheelchairs who, though nonambulatory, could be transported daily by auto mobile from their homes to alternative care sources without any adverse impact.  Conversely, there are instances where an individuals condition would be adversely affected by daily transportation to a care facility, even though the individual is able to a mbulate to some extent.
(Medicare Benefit Policy Manual)
EXAMPLE:  A 75 -year-old woman has suffered a cerebrovascular accident and cannot climb stairs safely.  The patient lives alone in a second -floor apartment accessible only by climbing a flight of stairs.  She requires physical therapy and occupational therapy on alternate days, and they are available in a CORF one mile away from her apartment.  However, because of her inability to negotiate the stairs, the daily skilled services she requires cannot, as a practical matter, be provided to the patient outside t he SNF.   The practical matter criterion should never be interpreted so strictly that it results in the automatic denial of coverage for patients who have been meeting all of the SNF level of care requirements, but who have occasion to be away from the SNF for a brief period of time.  While most beneficiaries requiring a SNF level of care find that they are unable to leave the facility, the fact that a patient is granted an outside pass or short leave of absence for the purpose of attending a special religious service, holiday meal, family occasion, going on a car ride, or for a trial visit home, is not, by itself evidence that the individual no longer needs to be in a SNF for the receipt of required skilled care.  Where frequent or prolonged periods away from the S NF become possible, the A/B MAC (A) may question whether the patients care can, as a practical matter, only be furnished on an inpatient basis in a SNF.  Decisions in these cases should be based on information reflecting the care needed and received by the patient while in the SNF and on the arrangements needed for the provision, if any, of this care during any absences.  (See the Medicare Benefit Policy Manual, Chapter 3, Duration of Covered Inpatient Services, 20.1.2, for counting inpatient days during a leave of absence.)
(Medicare Benefit Policy Manual)
A conservative approach to retain the presumption for limitation of liability may lead a facility to notify patients that leaving the facility will result in denial of coverage.  Such a notice is not appropriate.  If a SNF determines that covered care is n o longer needed, the situation does not change whether the patient actually leaves the facility or not.  40 - Physician Certification and Recertification  of Extended Care Services  (Rev. 10880, Issued: 08- 06-21, Effective: 11 -08-21, Implementation: 11 -08-21)  Payment for covered posthospital extended care services may be made only if a physician (or, as discussed in 40.1 of this chapter, a physician extender) makes the required certification, and where services are furnished over a period of time, the required recertification regarding the services furnished.   The SNF must obtain and retain the required certification and recertification statements.  The A/B MAC (A) may request them to assist in determining medical necessity when necessary.  The SNF will determine how to obtain the required certification and recertification statements.  There is no requirement for a specific procedure or form as long as the approach adopted by the facility permits verification that the certification and recertification requirement is met.  Certification or recertification statemen ts may be entered on or included in forms, notes, or other records that would normally be signed in caring for a patient, or on a separate form.  Except as otherwise specified, each certification and recertification is to be separately signed.
(Medicare Benefit Policy Manual)
If the SNFs failure to obtain a certification or recertification is not due to a question of the necessity for the services, but to the physicians or physician extenders refusal to certify on other grounds (e.g., an objection in principle to the concept  of certification and recertification), the SNF cannot charge the beneficiary for covered items or services.  Its provider agreement precludes it from doing so.  If a physician or physician extender refuses to certify, because, in his/her opinion, the patient does not, as a practical matter, require daily skilled care for an ongoing condition for which he/she was receiving inpatient hospital services (or for a new condition that arose while in the SNF for treatment of that ongoing condition), the services are not covered and the facility can bill the patient directly.  The reason for the refusal to make the certification must be documented in the SNFs records.   Certifications must be obtained at the time of admission, or as soon thereafter as is reasonable and practicable (see Pub.100 -04, Medicare Claims Processing Manual, Chapter 6, 120.2, regarding the circumstances under which a resumption of SNF care followi ng a temporary break in SNF coverage would be considered a new admission under the SNF PPSs interrupted stay policy).  The routine admission order established by a physician is not a certification of the necessity for post -hospital extended care services for purposes of the program.  There must be a separate signed statement indicating that the patient will require on a daily basis SNF covered care.   In addition, only physicians may certify outpatient physical therapy and outpatient speech -language pathology services.   40.1 - Who May Sign the Certification or Recertification for Extended Care Services  (Rev. 261, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11- 05-19)
(Medicare Benefit Policy Manual)
40.1 - Who May Sign the Certification or Recertification for Extended Care Services  (Rev. 261, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11- 05-19)  A certification or recertification statement must be signed by the attending physician or a physician on the staff of the skilled nursing facility who has knowledge of the case, or by a physician extender (that is, a nurse practitioner (NP), a clinical nur se specialist (CNS) or, effective with items and services furnished on or after January 1, 2011, a physician assistant (PA)) who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the phys ician.   In this context, the definition of a direct employment relationship is set forth in the regulations at 20 CFR 404.1005, 404.1007, and 404.1009. Under the regulations at 42 CFR 424.20(e)(2)(ii), when a physician extender has a direct employment relationship with an entity other than the facility, and the employing entity has an agreement with the facility that includes the provision of general nursing services under the regulations at 42 CFR 409.21, an indirect employment relationship exists between the physician extender and the facility. By contrast, such an indirect employment relationship does not exist if the agreement between the facility and the physician extenders employer solely involves the performance of delegated physician tasks under the regulations at 42 CFR 483.30(e).   Further information regarding certification and recertification of extended care services, including details on the content of the certification or recertification, timing of recertifications and the impact of delays on certifications and recertifications,  appears in Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, Physician Certification and Recertification of Services, 40 - 40.6.  50 - Covered Extended Care Services  (Rev. 1, 10-01-03)  A3-3133, SNF-230
(Medicare Benefit Policy Manual)
Patients covered under hospital insurance are entitled to have payment made on their behalf for covered extended care services.  Payment may be based on reasonable cost or be under the SNF Prospective Payment System (see 10).  The facility may charge the beneficiary for services they request that are not included in the PPS rate or otherwise covered by Medicare (i.e. extra meals for family members).   An inpatient  is a person who has been admitted to a skilled nursing facility or swing bed hospital for bed occupancy for purposes of receiving inpatient services.  A person is considered an inpatient if formally admitted as an inpatient with the expectation that they will remain at least overnight and occupy a bed even though it later develops that they can be discharged and do not actually use a bed overnight.  NOTES:   1.  Custodial care (see Medicare Benefit Policy Manual, Chapter 16, General Exclusions from Coverage, 110) is not a covered extended care service.  2.  When patients requiring inpatient hospital services occupy beds in a SNF, they are considered inpatients of the SNF.  In such cases, the services furnished in the SNF may not be considered inpatient hospital services, and payment may not be made under the program for such services.  Such a situation may arise where the SNF is a distinct part of an institution the remainde r of which is a hospital, and either there is no bed available in the hospital, or for any other reason the institution fails to place the patient in the appropriate bed.  The same rule applies where the SNF is a separate institution.  For the same reason, where patients who require extended care services occupy beds in a hospital, payment cannot be made on their behalf for the services furnished to them in the hospital, unless the services are extended care services furnished pursuant to a swing bed approval.  (See Medicare Benefit Policy Manual, Chapter 1, Inpatient Hospital Services, 10.)  3.  When patients who require SNF services are placed in a noncertified part of an institution which contains a participating distinct part SNF, the services may be paid under certain conditions, based on the limitation of liability provisions.  (See Medicare Claims Processing Manual, Chapter 30, Limitation of Liability, 10.4.)  The extended care services in 50.1 - 50.9, below, are covered under hospital insurance.
(Medicare Benefit Policy Manual)
The extended care services in 50.1 - 50.9, below, are covered under hospital insurance.   50.1 - Nursing Care Provided by or Under the Supervision of a Registered Professional Nurse  (Rev. 1, 10- 01-03)  A3-3133.1, SNF -230.1   Nursing care provided by or under the supervision of a registered professional nurse is covered.   However, the services of a private -duty nurse or other private -duty attendant are not covered.  Private- duty nurses or private -duty attendants are registered professional nurses, licensed practical nurses, or any other trained attendant whose services ordi narily are rendered to, and restricted to, a particular patient by arrangement between the patient and the private -duty nurse or attendant.  Such persons are engaged or paid by an individual patient or by someone acting on their behalf, including a SNF tha t initially incurs the cost and looks to the patient for payment for such noncovered services.  Where the SNF acts on behalf of a patient, the services of the private- duty nurse or other attendant under such an arrangement are not extended care services regardless of the control which the SNF may exercise with respect to the services rendered by such  private -duty nurse or attendant.  50.2 - Bed and Board in Semi -Private Accommodations Furnished in Connection With Nursing Care  (Rev. 1, 10- 01-03)  A3-3133.2, SNF -230.2   (See Medicare Benefit Policy Manual, Chapter 1, Inpatient Hospital Services, 10.1, for provisions relating to inpatient accommodations.)   50.3 - Physical Therapy, Speech -Language Pathology, and Occupational Therapy Furnished by the Skilled Nursing Facility or by Others Under Arrangements With the Facility and Under Its Supervision  (Rev. 242, Issued: 03- 16-18, Effective: 06 -19-18, Implementation: 06- 19-18)
(Medicare Benefit Policy Manual)
Physical therapy (PT), speech -language pathology (SLP), and occupational therapy (OT) services must be provided by the SNF or by others under arrangements with the SNF for beneficiaries in either a covered Part A stay or a non -covered stay in the SNF (see Pub. 100-04, Medicare Claims Processing Manual, Chapter 6, 20.5, for a more detailed discussion of therapy services under consolidated billing, the SNF bundling requirement). Bundling of therapy services to the SNF is not required for beneficiaries residing in a non- certified portion of the same institution that also includes a participating distinct part SNF. See Chapter 7, SNF Part B Billing, 10 in the Medicare Claims Processing Manual, for a clarification of bill types used to make this distinction c lear in billing. For a discussion of skilled therapy (that is, PT, SLP, and OT) services in the context of the SNF level of care criteria, see 30.4ff. of this chapter.   50.4 - Medical Social Services to Meet the Patients Medically Related Social Needs  (Rev. 1, 10- 01-03)  A3-3133.4, SNF -230.4   Medical social services are those social services, which contribute meaningfully to the treatment of a patients condition.  Such services include, but are not limited to:   a. Assessment of the social and emotional factors related to the patients illness, his or her need for care, response to treatment, and adjustment to care in the facility;   b. Appropriate action to obtain case work services to assist in resolving problems in these areas; and   c. Assessment of the relationship of the patients medical and nursing requirements to his or her home situation, financial resources, and the community resources available to him or her in making the decision regarding their discharge.   50.5 - Drugs and Biologicals (Rev. 1, 10- 01-03)
(Medicare Benefit Policy Manual)
50.5 - Drugs and Biologicals (Rev. 1, 10- 01-03)  A3-3133.5, SNF -230.5, Rev. A3- 1838 dated 06/01, A3- 3133.5.A, SNF -230.5.A, A3-3133.5.B, SNF -230.5.B, A3- 3133.5.C, SNF -230.5.C, A3- 3133.5.D, SNF -230.5.D   Drugs and biologicals for use in the facility, which are ordinarily furnished by the facility for the care and treatment of inpatients, are covered.  Such drugs and biologicals are not limited to those routinely stocked by the skilled nursing facility but include those obtained for the patient from an outside source, such as a pharmacy in the community.  Drugs and biologicals are included in the SNF PPS except for those Part B drugs specifically excluded.  Since the provision of drugs and biologicals is considered an essential part of skilled nursing care, a facility must assure their availability to inpatients in order to be found capable of furnishing the level of care required for participation in the program.  When a facility secures drugs and biological s from an outside source, their availability is assured only if the facility assumes financial responsibility for the necessary drugs and biologicals, i.e., the supplier looks to the facility, not the patient, for payment.  Payment may not be made for particular uses of drugs that the FDA has expressly disapproved or that are designated as not covered in the Medicare National Coverage Determinations Manual, chapter 2.
(Medicare Benefit Policy Manual)
If the A/B MAC (A) has reason to question whether the FDA has approved a drug or biological for marketing, it will obtain satisfactory evidence of FDAs approval.  Acceptable evidence includes a copy of the FDAs letter to the drugs manufacturer approving the new drug application (NDA); or listing of the drug or biological in the FDAs Approved Drug Products or FDA Drug and Device Product Approvals; or a copy of the manufacturers package insert, approved by the FDA as part of the labeling of the drug, containing its recommended uses and dosage, as well as possible adverse reactions and recommended precautions in using it.  When necessary, the Medicare regional office may be able to help in obtaining information.  See instruction in the Medicare Benefit Policy Manual, Chapter 1, Inpatient Hospital Services, 30.1, Drugs Included in the Drug Compendia, which also apply to drugs furnished to SNF inpatients.  However, drugs not included, or approved for inclusion, in the drug compendia are nevertheless covered in a SNF if such drug:   1. Was furnished the patient during their prior hospitalization;   2. Was approved for use in the hospital by the hospitals pharmacy and drug therapeutics (or equivalent) committee;  3. Is required for the continuing treatment of the patient in the skilled nursing facility; and   4. Is reasonable and necessary.   Under the limited circumstances mentioned in items 1 through 4 above, a combination drug approved by a hospital pharmacy and drug therapeutics committee may also be covered as an extended care service.   Rules for drugs and biologicals applicable to hospital inpatients found in the Medicare Benefit Policy Manual, Chapter 1, Inpatient Hospital Services, 30, 30.3, and 30.5, also apply to inpatients of SNFs. They are:    General information concerning drugs and biologicals furnished to inpatients;    Combination drugs; and   Drugs for use outside the SNF.  50.6 - Supplies, Appliances, and Equipment  (Rev. 1, 10- 01-03)  A3-3133.6, SNF -230.7
(Medicare Benefit Policy Manual)
 Drugs for use outside the SNF.  50.6 - Supplies, Appliances, and Equipment  (Rev. 1, 10- 01-03)  A3-3133.6, SNF -230.7   Instructions in the Medicare Benefit Policy Manual, Chapter 1, Hospital Inpatient Services, 40 - Supplies, Appliances, and Equipment, also apply to SNF inpatients.  50.7 - Medical Service of an Intern or Resident -in-Training  (Rev. 228, Issued: 10-13-16, Effective: 10-18-16, Implementation: 10-18-16)  The medical services of an intern or resident- in-training under an approved teaching program of a hospital with which the facility has in effect the required transfer agreement are covered under hospital insurance (see Pub. 100- 01, Medicare General Information, Eligibility, and Entitlement Manual, chapter 5, section 30.2 for a discussion of the SNFs required transfer agreement with a hospital).  An approved teaching program means a program approved by the Council on Medical Education of the American Medical Association or, in the case of an osteopathic hospital, approved by the Committee on Hospitals of the Bureau of Professional Education of the American Osteopathic Association.  In the case of services of an intern or resident -in-training in the field of dentistry in a hospital or osteopathic hospital, the teaching program must have the approval of the Council on Dental Education of the America n Dental Association.  The medical and surgical services furnished to the facilitys patients by interns and residents -in-training of a hospital with which the facility has a transfer agreement are covered under medical insurance if the services are not covered under hospital insurance.   50.8 - Other Services  (Rev. 1, 10-01-03)  A3-3133.9, SNF-230.10  50.8.1 - General  (Rev. 1, 10-01-03)  A3-3133.9.A, SNF-230.10.A
(Medicare Benefit Policy Manual)
50.8.1 - General  (Rev. 1, 10-01-03)  A3-3133.9.A, SNF-230.10.A  Other services that are necessary to the health of the patients are covered if the services are generally provided by, or under arrangements made by, skilled nursing facilities.  The medical and other health services described in the Medicare Benefit Policy Manual, Chapter 6, Hospital Services Covered Under Part B, 10 - 10.2.4, are generally provided by, or under arrangements made by, skilled nursing facilities and are therefore extended care services.  For coverage of diagnostic services and radiologic al therapy under Part A, the conditions described in 70.1 must be met.   Items or services that would not be included as inpatient hospital services if furnished to an inpatient of a hospital are also excluded from coverage as extended care services.  For instance, the provision of personal laundry services by skilled nursing f acilities is not a covered service under Medicare, since it would not be covered if provided to an inpatient of an acute care hospital.  See the Medicare Benefit Policy Manual, Chapter 6, Hospital Services Covered Under Part B, 10, for covered inpatient hospital services.  The use of an operating room and any special equipment, supplies, or services would not constitute covered extended care services except when furnished to the facility by a hospital with which the facility has a transfer agreement, since operating rooms ar e not generally maintained by skilled nursing facilities.  However, supplies and nursing services connected with minor surgery performed in a skilled nursing facility that does not require the use of an operating room or any special equipment or supplies a ssociated with such a room would be covered extended care services and paid as part of inpatient SNF PPS.   50.8.2 - Respiratory Therapy  (Rev. 242, Issued: 03- 16-18, Effective: 06 -19-18, Implementation: 06- 19-18)
(Medicare Benefit Policy Manual)
50.8.2 - Respiratory Therapy  (Rev. 242, Issued: 03- 16-18, Effective: 06 -19-18, Implementation: 06- 19-18)  Prior to BBA 1997, respiratory therapy could be provided by a SNF either under an arrangement with a hospital with which the SNF had a transfer agreement or through the SNFs nursing staff.  Section 4432(b)(5)(D) of the BBA amended section 1861(h)(7)  of the Act to cover the full range of services that SNFs generally provide, either directly or under arrangements with any qualified outside source.  As a result, the services of respiratory therapists are now covered under Part A when provided under arra ngements made directly between the SNF and any qualified respiratory therapist, regardless of whether the therapist is employed by the SNFs transfer agreement hospital (see the regulations at 42 CFR 409.27(b)).   60 - Covered Extended Care Days  (Rev. 1, 10- 01-03)  Not Applicable   See the Medicare Benefit Policy Manual, Chapter 3, Duration of Covered Inpatient Services, for the following topics:    Post-hospital extended care benefit days available in a benefit period;    Definition of an inpatient benefit day;    Late discharge;    Leave of absence;    Discharge or death on first day of entitlement or participation; and    Inpatient service days counting toward benefit maximums.   70 - Medical and Other Health Services Furnished to SNF Patients  (Rev. 228, Issued: 10 -13-16, Effective: 10 -18-16, Implementation: 10- 18-16)  The medical and other health services listed below are covered under Part B when furnished by a participating SNF either directly or under arrangements to inpatients who are not entitled to have payment made under Part A (e.g., benefits exhausted or 3- day prior -stay requirement not met).   Services payable under Part B are:    Diagnostic x- ray tests, diagnostic laboratory tests, and other diagnostic tests;    X-ray, radium, and radioactive isotope therapy, including materials and services of technicians;    Surgical dressings, and splints, casts, and other devices used for reduction of fractures and dislocations;