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Written by: Darlene D'Altorio-Jones (1959-2015) on Tuesday, May 8, 2012 Posted in: Outpatient Rehab

Most often than not, therapy services already provided can be unfunded or denied based on two words – Medically Necessary.

It is a concept that has gained popularity for denial from pre-authorization to post provided and unfunded care.  Yet there are criteria aimed around the concepts, that if taught well, staff could easily defend requirements.

Criteria for Medically Necessary therapy care are generally met when:

  • Therapy is aimed at PREVENTING disability, improving, adapting or restoring functions impaired or lost permanently as a result of illness, injury, loss of body parts or congenital abnormalities; AND
  • Conditions require SKILLED  knowledge, and judgement for education and training as part of a skilled plan of treatment due to the complexity and sophistication of the medical condition; AND
  • Expectation is that services will result in a practical improvement in the level of FUNCTION within a reasonable and predictable period of time.

Given these conditions, it would not be expected that function could reasonably be expected to improve normally or to such potential without SKILLED services within similar time frames.

* Skilled services are often identified as provided by a qualified practitioner. Qualified is defined through CMS and state practice guidelines.

Criteria must clearly be stated in the evaluation and plan of care and then validated by demonstrating the expected practical improvement has occurred within the time line predicted.  Where there is variation, appropriate cause and continued skilled intervention mediates the variance. So often the intended goal of service and the impact of that goal is not stated nor revisited so that functional gain toward attainment is clear.

When staff embrace the criteria within those three bullets and then revisit those requirements at appropriate intervals to document care, medical necessity is no longer a mystery and approved and reimbursed care occurs more successfully.