Medicare regulations set out coverage rules for home health care, including physical therapy, occupational therapy, and speech-language pathology services. Significantly, especially for people with longer term and chronic conditions, the regulations reiterate that skilled care includes services that are intended to maintain a person’s condition. The regulations also forbid the use of “rules of thumb” to deny care, including rules that require restoration potential. As the Centers for Medicare & Medicaid Services stated when issuing the regulation in 2010:
“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, and therefore coverable, 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 each individual beneficiary. Rules of thumb, whether issued in print, electronically, or via AI are prohibited as the basis to determine Medicare coverage.
See, 75 Fed. Reg. 70,395 (Nov. 17, 2010); 42 CFR §409.44(c)(2)(i).