- Coverage turns on whether skilled care (nursing or therapy) is required.
- Restoration potential is not the deciding factor.
- Skilled care to maintain condition or slow decline is coverable.
- Medicare should not be denied because the beneficiary has a chronic condition or needs services to maintain condition/function.
- An Individualized Assessment of each claim is required.
- Rules of thumb should not be used.
See CMS.gov – www.cms.gov/medicare/settlements/jimmo
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