Page 190 - Medicare Benefit Policy Manual

performance of safe and effective services in a maintenance program. Such
skilled care is necessary for the performance of a safe and effective maintenance
program only when (a) the therapy procedures required to maintain the patient’s
current function or to prevent or slow further deterioration are of such complexity
and sophistication that the skills of a qualified therapist are required to furnish the
therapy procedure or (b) the particular patient’s special medical complications
require the skills of a qualified therapist to furnish a therapy service required to
maintain the patient’s current function or to prevent or slow further deterioration,
even if the skills of a therapist are not ordinarily needed to perform such therapy
procedures. Unlike coverage for rehabilitation therapy, coverage of therapy
services to carry out a maintenance program does not depend on the presence or
absence of the patient’s potential for improvement from the therapy.

The deciding factors are always whether the services are considered reasonable, effective
treatments for the patient’s condition and require the skills of a therapist, or whether they
can be safely and effectively carried out by nonskilled personnel or caregivers.

The examples that follow are intended to provide illustrations of how coverage
determinations are made. These examples are not intended to include all possible
situations in which coverage is provided or all reasons for denying coverage. Rather they
are intended only to show how to analyze the coverage issue.

Example #1 reflects a typical outpatient scenario in which a patient has been receiving
ongoing therapy under a physical therapy plan of care and the physical therapist begins
the establishment of the maintenance program prior to the patient’s anticipated discharge
date.

EXAMPLE: A patient with Parkinson’s disease is nearing the end of a rehabilitative
physical therapy program and requires the services of a therapist during the last week(s)
of treatment to determine what type of exercises will contribute the most to maintain
function or to prevent or slow further deterioration of the patient’s present functional
level following cessation of treatment. In such situations, the establishment of a
maintenance program appropriate to the capacity and tolerance of the patient by the
qualified therapist, the instruction of the patient or family members in carrying out the
program, and such reassessments and/or reevaluations as may be required may constitute
covered therapy because of the need for the skills of a qualified therapist.

Example #2 is an outpatient scenario in which a patient who has not been receiving
ongoing therapy under a therapy plan of care needs a maintenance plan.

EXAMPLE: A patient with multiple sclerosis needs a maintenance program to slow or
prevent deterioration in communication ability caused by the medical condition. Therapy
services from a qualified speech-language pathologist may be covered to establish a
maintenance program even though the patient’s current medical condition does not yet
justify the need for individual skilled therapy sessions. Evaluation, establishment of the
program, and training the family or support personnel may require the skills of a therapist