Medicare coverage turns on whether the care in question is reasonable and necessary and, in many settings, whether it includes skilled services. This is key to the Jimmo federal court settlement and decisions. In Summary:
- Coverage turns on whether skilled care is required, not on whether the care will improve the individual’s condition.
- Improvement is not required.
- Restoration potential is not the deciding factor.
- Coverage is available for necessary services to maintain an individual’s condition.
- Medicare coverage should not be denied because the individual has a chronic condition.
- An “individual assessment” is required to determine whether each claim is eligible for coverage.
- “Rules of thumb” cannot be used to deny coverage (whether from a decision tree, generalized norms, screens, or AI).
Per CMS, “This is long-standing criteria, consistent with regulations.”
See, Important Message About Jimmo at CMS.gov