Page 186 - Medicare Benefit Policy Manual

exercises to promote overall fitness and flexibility and activities to provide diversion or
general motivation, do not constitute therapy services for Medicare purposes. Also,
services not provided under a therapy plan of care, or provided by staff who are not
qualified or appropriately supervised, are not payable therapy services.

Examples of coverage policies that apply to all outpatient therapy claims are in this
chapter, in Pub. 100-04, chapter 5, and Pub. 100-08, chapter 13. Some policies in other
manuals are repeated here for emphasis and clarification. Further details on documenting
reasonable and necessary services are found in section 220.3 of this chapter.

B. Reasonable and Necessary

To be considered reasonable and necessary, each of the following conditions must be
met. (This is a representative list of required conditions and does not fully describe
reasonable and necessary services. See the remainder of this section and associated
information in section 230.)

• The services shall be considered under accepted standards of medical practice to
be a specific and effective treatment for the patient’s condition. Acceptable
practices for therapy services are found in:

o Medicare manuals (such as this manual and Publications 100-03 and 100-04),

o Contractors Local Coverage Determinations (LCDs and NCDs are available
on the Medicare Coverage Database: http://www.cms.hhs.gov/mcd, and

o Guidelines and literature of the professions of physical therapy, occupational
therapy and speech-language pathology.

• The services shall be of such a level of complexity and sophistication or the
condition of the patient shall be such that the services required can be safely
and effectively performed only by a therapist, or in the case of physical
therapy and occupational therapy by or under the supervision of a therapist.
Services that do not require the performance or supervision of a therapist are
not skilled and are not considered reasonable or necessary therapy services,
even if they are performed or supervised by a qualified professional.
Medicare coverage does not turn on the presence or absence of a beneficiary’s
potential for improvement from the therapy, but rather on the beneficiary’s
need for skilled care. (For additional guidance, see subsection D below
related to Maintenance Programs.)

• If the contractor determines the services furnished were of a type that could
have been safely and effectively performed only by or under the supervision
of such a qualified professional, the contractor shall presume that such
services were properly supervised when required. However, this presumption
is rebuttable and, if in the course of processing a claim, the contractor finds