Page 189 - Medicare Benefit Policy Manual

patient’s condition and require the skills of a therapist, or whether they can be safely and
effectively carried out by nonskilled personnel.

Rehabilitative therapy is not required to effect improvement or restoration of function
when a patient suffers a transient and easily reversible loss or reduction of function (e.g.,
temporary and generalized weakness, which may follow a brief period of bed rest
following surgery) that could reasonably be expected to improve spontaneously as the
patient gradually resumes normal activities. Therapy furnished in such situations is not
considered reasonable and necessary for the treatment of the individual’s illness or injury
and the services are not covered.

If at any point in the treatment of an illness it is determined that the treatment is not
rehabilitative, the services will no longer be considered reasonable and necessary under
this section. (See Section 220.2 D for additional covered therapy benefits under
maintenance programs). Services that are not reasonable or necessary are excluded from
coverage under §1862(a)(1)(A) of the Act.

D. Maintenance Programs

Skilled therapy services that do not meet the criteria for rehabilitative therapy may be
covered in certain circumstances as maintenance therapy under a maintenance program.
The goals of a maintenance program would be, for example, to maintain functional status
or to prevent or slow further deterioration in function.

Coverage for skilled therapy services related to a reasonable and necessary maintenance
program is available in the following circumstances:

• Establishment or design of maintenance programs. If the specialized skill,
knowledge and judgment of a qualified therapist are required to establish or
design a maintenance program to maintain the patient’s current condition or to
prevent or slow further deterioration, the establishment or design of a
maintenance program by a qualified therapist is covered. If skilled therapy
services by a qualified therapist are needed to instruct the patient or appropriate
caregiver regarding the maintenance program, such instruction is covered. If
skilled therapy services are needed for periodic reevaluations or reassessments of
the maintenance program, such periodic reevaluations or reassessments are
covered.

• Delivery of maintenance programs. Once a maintenance program is
established, coverage of therapy services to carry out a maintenance program
turns on the beneficiary’s need for skilled care. A maintenance program can
generally be performed by the beneficiary alone or with the assistance of a family
member, caregiver or unskilled personnel. In such situations, coverage is not
provided. However, skilled therapy services are covered when an individualized
assessment of the patient’s clinical condition demonstrates that the specialized
judgment, knowledge, and skills of a qualified therapist are necessary for the