To qualify for most Medicare-covered care, the individual must need and receive skilled care. Skilled services include nursing, physical therapy, occupational therapy, and speech-language pathology services. In November 2010, CMS revised its regulations to reiterate this coverage principle and how coverage determinations are to be made.
Importantly, the revision “clarified” that skilled care can include services intended to maintain a person’s condition and that “rules of thumb” should not be used to deny coverage, including such 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. [Emphasis added.]
Coverage rules of thumb are prohibited – whether from a printed decision-tree, a computerized program, or an AI screen. Medicare determinations must be based on an individual’s needs and circumstances. To determine whether coverage and care are appropriate, decision-makers must review accepted standards of clinical practice and consider whether a professional is needed for the care to be safe and effective for the individual in question. Individualized assessments are required. Decisions based on general rules of thumb are prohibited. That includes AI.
See, 75 Fed. Reg. 70,395 (Nov. 17, 2010); 42 CFR §409.44(c)(2)(i)