evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
 The services must be of a level of complexity and sophistication, or the condition of the patient must be of a nature that requires the judgment, knowledge, and skills of a qualified physical therapist;    The services must be provided with the expectation, based on the assessment made by the physician of the patients restoration potential, that the condition of the patient will improve materially in a reasonable and generally predictable period of time; or, the services must be necessary for the establishment  of a safe and effective maintenance program;  or, the services must require the skills of a qualified therapist for the performance of a safe and effective maintenance program.  NOTE:   See Section E. Maintenance Therapy for more guidance regarding when skilled therapy services are necessary for the performance of a safe and effective maintenance program.    The services must be considered under accepted standards of medical practice to be specific and effective treatment for the patients condition; and,    The services must be reasonable and necessary for the treatment of the patients condition; this includes the requirement that the amount, frequency, and duration of the services must be reasonable.   EXAMPLE 1:   An 80- year old, previously ambulatory, post -surgical patient has been bed -bound for 1 week, and, as a result, had developed muscle atrophy, orthostatic hypotension, joint stiffness and lower extremity edema.  To the extent that the patient requires a brief  period of daily skilled physical therapy to restore lost functions, those services are reasonable and necessary and must be documented in the medical record (see 30.2.2.1).  EXAMPLE 2:
(Medicare Benefit Policy Manual)
A patient with congestive heart failure also has diabetes and previously had both legs amputated above the knees.  Consequently, the patient does not have a reasonable potential to achieve ambulation, but still requires daily skilled physical therapy to le arn bed mobility and transferring skills, as well as functional activities at the wheelchair level.  If the patient has a reasonable potential for achieving those functions in a reasonable period of time in view of the patients total condition, the physic al therapy services are reasonable and necessary and must be documented in the medical record (see 30.2.2.1).  Physical therapy services are not reasonable and necessary and would not be covered if the expected results are insignificant in relation to the extent and duration of physical therapy services that would be required to achieve those results.  Some SNF inpatients do not require skilled physical therapy services but do require services, which are routine in nature.  When services can be safely and effectively performed by supportive personnel, such as aides or nursing personnel, without the super vision of a physical therapist, they do not constitute skilled physical therapy.  Additionally, services involving activities for the general good and welfare of the patient (e.g., general exercises to promote overall fitness and flexibility and activities  to provide diversion or general motivation) do not constitute skilled physical therapy.   30.4.1.2 - Application of Guidelines  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14) A3-3132.3.A.2, SNF -214.3.A.2  Some of the more common skilled physical therapy modalities and procedures are:   A.  Assessment   The skills of a physical therapist are required for the ongoing assessment of a patients rehabilitation needs and potential.  Skilled rehabilitation services concurrent with the management of a patients care plan include tests and measurements of range o f motion, strength, balance, coordination, endurance, and functional ability.  B.  Therapeutic Exercises   Therapeutic exercises, which must be performed by or under the supervision of the qualified physical therapist, due either to the type of exercise employed or to the condition of the patient.  C.  Gait Training
(Medicare Benefit Policy Manual)
Therapeutic exercises, which must be performed by or under the supervision of the qualified physical therapist, due either to the type of exercise employed or to the condition of the patient.  C.  Gait Training   Gait evaluation and training furnished to a patient whose ability to walk has been impaired by neurological, muscular, or skeletal abnormality often require the skills of a qualified physical therapist.  Repetitious exercises to improve gait, or to maintain strength and endurance, and assistive walking can be appropriately provided by supportive personnel, e.g., aides or nursing personnel, and would not necessarily require the skills of a physical therapis t.  Thus, such services are not inherently skilled.  However, see 30.2.2. for the specific circumstances in which an ordinarily nonskilled service can nevertheless be considered skilled.  Documentation of the patients condition in the medical record must  describe the circumstances which delineate the need for skilled rather than unskilled services during gait training.   D.  Range of Motion   Only the qualified physical therapist may perform range of motion tests and, therefore, such tests  are skilled physical therapy.  Range of motion exercises  constitute skilled physical therapy only if they are part of active treatment for a specific disease state which has resulted in a loss or restriction of mobility (as evidenced by physical therapy notes showing the degree of motion lost, the degree to be restored and the impact on mobility and/or function).   Generally, range of motion exercises which are not related to the restoration of a specific loss of function may be provided safely by supportive personnel, such as aides or nursing personnel, and as such would not necessarily require the skills of a physi cal therapist.  Passive exercises to maintain range of motion in paralyzed extremities that can be carried out by aides or nursing personnel would not be considered skilled care.  However, see 30.2.2. for the specific circumstances in which an ordinarily nonskilled servi ce can nevertheless be considered skilled.  Documentation of the patients condition in the medical record must describe the circumstances which delineate the need for skilled rather than unskilled services during range of motion training.  E.  Maintenance Therapy
(Medicare Benefit Policy Manual)
E.  Maintenance Therapy   Therapy services in connection with a maintenance program are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a qualified therapist.  (See 42CFR 409.32)  If all  other requirements for coverage under the SNF benefit are met, skilled therapy services are covered when an individualized assessment of the patients clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified ther apist are necessary for the performance of a safe and effective maintenance program.  Such a maintenance program to maintain the patients current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program.  When, however, the individualized assessment does not demonstrate such a necessity for skilled care, including when the performance of a maintenance program does not require the skills of a thera pist because it could safely and effectively be accomplished by the patient or with the assistance of non-therapists, including unskilled caregivers, such maintenance services do not constitute a covered level of care.   A service is not considered a skilled therapy service merely because it is furnished by a therapist or by a therapist/therapy assistant under the direct supervision of a therapist.  If a service can be self -administered or safely and effectively furnished by an unskilled person, without the direct supervision of a therapist, the service cannot be regarded as a skilled therapy service even when a therapist actually furnishes the service.  Similarly, the unavailability of a competent person to provide a non- skilled service, regardless of the importance of the service to the patient, does not make it a skilled service when a therapist furnishes the service.   However, even though it would not otherwise require the skills of a therapist, the performance of a maintenance program may nevertheless require such skills under certain circumstances.  Specifically, skilled therapy services are necessary for the performance of a safe and effective maintenance program only when (a) the particular patients special medical complications require the skills of a qualified therapist to perform a therapy service that would otherwise be considered non- skilled; or (b) the needed therapy procedures are of such complexity that the skills of a qualified therapist are required to perform the procedure.
(Medicare Benefit Policy Manual)
If the specialized knowledge and judgment of a qualified therapist are required, the establishment or design of a maintenance program by a qualified therapist, the instruction of the beneficiary or appropriate caregiver by a qualified therapist regarding a  maintenance program, and the necessary periodic reevaluations by a qualified therapist of the beneficiary and maintenance program are considered skilled therapy services, to the extent provided by regulation.  EXAMPLE:  A patient with Parkinsons disease may require the services of a physical therapist to determine the type of exercises that are required to maintain his present level of function.  The initial evaluation of the patients needs, the designing of a maintenance program which is appropriate to the capacity and tolerance of the patient and the treatment objectives of the physician, the instruction of the patient or supportive personnel (e.g., aides or nursing personnel) in the carrying out of the progr am, would constitute skilled physical therapy and must be documented in the medical record (see 30.2.2.1).  While a patient is receiving a skilled physical therapy program, the physical therapist should regularly reevaluate the patients condition and adjust any exercise program the patient is expected to carry out independently or with the aid of supportive per sonnel to maintain the function being restored.  Consequently, by the time it is determined that no further skilled therapy services are needed, i.e., by the end of the last skilled session, the physical therapist will have already designed any maintenance  program required and instructed the patient or supportive personnel in the carrying out of the program.  F.  Ultrasound, Shortwave, and Microwave Diathermy Treatments   These modalities must always be performed by or under the supervision of a qualified physical therapist.   G.  Hot Packs, Infra- Red Treatments, Paraffin Baths, and Whirlpool Baths
(Medicare Benefit Policy Manual)
These modalities must always be performed by or under the supervision of a qualified physical therapist.   G.  Hot Packs, Infra- Red Treatments, Paraffin Baths, and Whirlpool Baths   Heat treatments and baths of this type ordinarily do not require the skills of a qualified physical therapist.  However, the skills, knowledge, and judgment of a qualified physical therapist might be required in the giving of such treatments or baths in a particular case, e.g., where the patients condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications.  There must be clear documentation in the medical record of the special medical complic ations that describe the need for the skilled therapy provided by the therapist.  30.4.2 - Speech -Language Pathology  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14)  See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 1, Inpatient Hospital Services.   See 30.4.1.2.E. Maintenance Therapy for the specific circumstances in which speech -language pathology therapy is appropriate in connection with a maintenance program.   30.4.3 - Occupational Therapy  (Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14) A3-3132.3.C, SNF-214.3.C  See Pub. 100-02, Medicare Benefit Policy Manual, Chapter 1, Inpatient Hospital Services.   See 30.4.1.2.E. Maintenance Therapy for the specific circumstances in which occupational therapy is appropriate in connection with a maintenance program.  30.5 - Nonskilled Supportive or Personal Care Services  (Rev. 1, 10-01-03)  A3-3132.4, SNF-214.4  The following services are not skilled services unless rendered under circumstances detailed in 30.2:   Administration of routine oral medications, eye drops, and ointments (the fact that patients cannot be relied upon to take such medications themselves or that State law requires all medications to be dispensed by a nurse to institutional patients would not change this service to a skilled service);   General maintenance care of colostomy and ileostomy;
(Medicare Benefit Policy Manual)
 General maintenance care of colostomy and ileostomy;   Routine services to maintain satisfactory functioning of indwelling bladder catheters (this would include emptying and cleaning containers and clamping the tubing);   Changes of dressings for uninfected post-operative or chronic conditions;   Prophylactic and palliative skin care, including bathing and application of creams, or treatment of minor skin problems;   Routine care of the incontinent patient, including use of diapers and protective sheets;    General maintenance care in connection with a plaster cast (skilled supervision or observation may be required where the patient has a preexisting skin or circulatory condition or requires adjustment of traction);   Routine care in connection with braces and similar devices;    Use of heat as a palliative and comfort measure, such as whirlpool or steam pack;    Routine administration of medical gases after a regimen of therapy has been established (i.e., administration of medical gases after the patient has been taught how to institute therapy);    Assistance in dressing, eating, and going to the toilet;    Periodic turning and positioning in bed; and   General supervision of exercises, which have been taught to the patient and the performance of repetitious exercises that do not require skilled rehabilitation personnel for their performance.  (This includes the actual carrying out of maintenance programs  where the performances of repetitive exercises that may be required to maintain function do not necessitate a need for the involvement and services of skilled rehabilitation personnel.  It also includes the carrying out of repetitive exercises to improve gait, maintain strength or endurance; passive exercises to maintain range of motion in paralyzed extremities which are not related to a specific loss of function; and assistive walking.)  (See Medicare Benefit Policy Manual, Chapter 1, Inpatient Hospital Services.)   30.6 - Daily Skilled Services Defined  (Rev. 249, Issued: 11- 02-18, Effective: 12 -04-18, Implementation: 12- 04-18)
(Medicare Benefit Policy Manual)
30.6 - Daily Skilled Services Defined  (Rev. 249, Issued: 11- 02-18, Effective: 12 -04-18, Implementation: 12- 04-18)  Skilled nursing services or skilled rehabilitation services (or a combination of these services) must be needed and provided on a daily basis, i.e., on essentially a 7- days-a-week basis.  A patient whose inpatient stay is based solely on the need for ski lled rehabilitation services would meet the daily basis requirement when they need and receive those services on at least 5 days a week.  (If therapy services are provided less than 5 days a week, the daily requirement would not be met.)   This requirement should not be applied so strictly that it would not be met merely because there is an isolated break of a day or two during which no skilled rehabilitation services are furnished and discharge from the facility would not be practical.  EXAMPLE:   A patient who normally requires skilled rehabilitation services on a daily basis  may exhibit extreme fatigue, which results in suspending therapy sessions for a day or two.  Coverage may continue for these days since discharge in such a case would not be practical.   In instances when a patient requires a skilled restorative nursing program to positively affect his functional well -being, the expectation is that the program be rendered at least 6 days a week.  (Note that when a patients skilled status is based on a res torative program, medical evidence must be documented to justify the services.  In most instances, it is expected that a skilled restorative program will be, at most, only a few weeks in duration.)   The daily basis requirement can be met by furnishing a single type of skilled service every day, or by furnishing various types of skilled services on different days of the week that collectively add up to daily skilled services.  However, arbitrarily st aggering the timing of various therapy modalities through the week, merely in order to have some type of therapy session occur each day, would not satisfy the SNF coverage requirement for skilled care to be needed on a daily basis.  To meet this requirem ent, the patient must actually need  skilled rehabilitation services to be furnished on each of the days that the facility makes such services available.
(Medicare Benefit Policy Manual)
It is not sufficient for the scheduling of therapy sessions to be arranged so that some therapy is furnished each day, unless the patient's medical needs indicate that daily therapy is required.  For example, if physical therapy is furnished on 3 days each week and occupational therapy is furnished on 2 other days each week, the daily basis requirement would b e satisfied only if there is a valid medical reason why both cannot be furnished on the same day.  The basic issue here is not whether the services are needed, but when  they are needed.  Unless there is a legitimate medical need for scheduling a therapy session each day, the daily basis requirement for SNF coverage would not be met.  30.7 - Services Provided on an Inpatient Basis as a Practical Matter  (Rev. 261, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11- 05-19) A3-3132.6, SNF -214.6   In determining whether the daily skilled care needed by an individual can, as a practical matter, only be provided in a SNF on an inpatient basis, the A/B MAC (A) considers the individuals physical condition and the availability and feasibility of using more economical alternative facilities or services.   As a practical matter, daily skilled services can be provided only in a SNF if they are not available on an outpatient basis in the area in which the individual resides or transportation to the closest facility would be:    An excessive physical hardship;    Less economical; or    Less efficient or effective than an inpatient institutional setting.   The availability of capable and willing family or the feasibility of obtaining other assistance for the patient at home should be considered.  Even though needed daily skilled services might be available on an outpatient or home care basis, as a practical matter, the care can be furnished only in the SNF if home care would be ineffective because the patient would have insufficient assistance at home to reside there safely.
(Medicare Benefit Policy Manual)
EXAMPLE: A patient undergoing skilled physical therapy can walk only with supervision but has a reasonable potential to learn to walk independently with further training.  Further daily skilled therapy is available on an outpatient or home care basis, but the patie nt would be at risk for further injury from falling, because sufficient supervision and assistance could not be arranged for the patient in his home.  In these circumstances, the physical therapy services as a practical matter can be provided effectively only in the inpatient setting.   30.7.1 - The Availability of Alternative Facilities or Services  (Rev. 261, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11- 05-19) A3-3132.6.A, SNF -214.6.A   Alternative facilities or services may be available to a patient when health care providers such as home health agencies are utilized.  These alternatives are not always available in all communities and even where they exist they may not be available when needed.   EXAMPLE: Where the residents of a rural community generally utilize the outpatient facilities of a hospital located some distance from the area, the hospital outpatient department constitutes an alternative source of care that is available to the community.  Roads in winter, however, may be impassable for some periods of time and in special situations institutionalization might be needed.   In determining the availability of more economical care alternatives, the coverage or noncoverage of that alternative care is not a factor to be considered.  Home health care for a patient who is not homebound, for example, may be an appropriate alternative in some cases.  The fact that Medicare cannot cover such care is irrelevant.   The issue is feasibility and not whether coverage is provided in one setting and not provided in another.  For instance, an individual in need of daily skilled physical therapy might be able to receive the services needed on a more economical basis from an  independently practicing physical therapist.  However, the fact that Medicare payment could not be made for the services because an expense limitation (if applicable) to the services of an independent physical therapist had been exceeded or because the pa tient was not enrolled in Part B, would not be a basis for determining that, as a practical matter, the needed care could only be provided in a SNF.   In determining the availability of alternate facilities or services, whether the patient or another resource can pay for the alternate services is not a factor to be considered.
(Medicare Benefit Policy Manual)
In determining the availability of alternate facilities or services, whether the patient or another resource can pay for the alternate services is not a factor to be considered.   30.7.2 - Whether Available Alternatives Are More Economical in the Individual Case  (Rev. 261, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11- 05-19) A3-3132.6.B, SNF -214.6.B   If the A/B MAC (A) determines that an alternative setting is available to provide the needed care, it considers whether the use of the alternative setting would actually be more economical in the individual case.   EXAMPLE 1:   If a patient's condition requires daily transportation to the alter native source of care (e.g., a hospital outpatient depart ment) by ambulance, it might be more economical from a health care delivery viewpoint to provide the needed care in the SNF setting.  EXAMPLE 2:   If needed care could be provided in the home, but the patients residence is so isolated that daily visits would entail inordinate travel costs, care in a SNF might be a more economical alternative.    30.7.3 - Whether the Patients Physical Condition Would Permit Utilization of an Available, More Economical Care Alternative  (Rev. 1, 10- 01-03)  A3-3132.6.C, SNF -214.6.C   In determining the practicality of using more economical care alternatives, the A/B MAC (A) considers the patients medical condition.  If the use of those alternatives would adversely affect the patients medical condition, the A/B MAC (A) concludes that as a practical matter the daily skilled services can only be provided by a SNF on an inpatient basis.