The key to coverage is whether the individual requires a skilled provider to ensure the services are safe and effective, not whether improvement is expected.
“Medicare coverage does not turn on the presence or absence of improvement from therapy, but rather on the beneficiary’s need for skilled care. (For additional guidance, see subsection D below related to Maintenance Programs.)”
- Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, Section 220 – Coverage of Outpatient Rehabilitation Services …
“… The goals of a maintenance program would be, for example, to maintain functional status or to prevent or slow further deterioration in function.
… skilled therapy services are covered when an individualized assessment of a patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills, of a qualified therapist are necessary for the performance of a safe and effective services in a maintenance program. …” [Emphasis added.]
- Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, Section 220 D, Maintenance Program
For more information see CMA’s
Outpatient Therapy Quick Guide