In November 2010, CMS revised its regulations to clarify Medicare coverage principles for skilled services. Most importantly, the revisions “clarified” that skilled care does include services intended to maintain a person’s condition and that no “rules of thumb” should be used to deny care, including rules that require restoration potential. Skilled care to maintain a condition or slow decline is covered. CMS also clarified that:
“Rules of thumb” in the Medicare medical review process are prohibited.… Any “rules of thumb” that would declare a claim not covered solely on the basis of elements, such as, lack of restoration potential, … or degree of stability, is [sic] unacceptable without individual review of all pertinent facts to determine if coverage may be justified.
To determine whether a service is skilled, the regulations direct decision-makers to review accepted standards of clinical practice and to consider whether a professional is needed for the service to be safe and effective for the particular beneficiary.
See, 75 Fed. Reg. 70,395 (Nov. 17, 2010); 42 CFR §409.44(c)(2)(i)