Clinical UM Guideline
Subject: Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
Guideline #: CG-REHAB-07 Publish Date: 10/06/2021
Status: Reviewed Last Review Date: 08/12/2021
Description

This document addresses skilled nursing and skilled rehabilitation services provided in the outpatient setting.

Skilled nursing and skilled rehabilitation services are those services, furnished pursuant to physician orders, that:

Note: Please see the following related documents for additional information:

Clinical Indications

Outpatient Skilled Nursing and Skilled Rehabilitation Services

Medically Necessary:

Outpatient skilled nursing services are considered medically necessary in the following circumstances:

  1. When the inherent complexity of a service required by an individual is such that it can be performed safely and effectively only by or under the general supervision of skilled nursing personnel; and
  2. When the likelihood of change in an individual’s condition requires skilled nursing personnel to observe and assess the individual in order to identify and evaluate the need for possible modification of treatment or initiation of additional medical procedures, until the treatment regimen is essentially stabilized; and
  3. When they are not custodial in nature (see definition of custodial care under “Discussion/General Information” section below).

Outpatient skilled rehabilitation services are considered medically necessary when all of the following conditions are met:

  1. Individual has a new (acute) medical condition or acute exacerbation of a chronic medical condition that has resulted in a decrease in functional ability such that they cannot adequately recover without therapy; and
  2. Individual’s overall medical condition and medical needs can be addressed in the outpatient setting; and
  3. Therapy must be reasonable and necessary for the individual’s condition, including the amount, duration and frequency of services and must be directly and specifically related to an active written treatment plan developed by physician and therapist; and
  4. Individual’s mental and physical condition prior to the onset of the medical condition indicates there is a potential for improvement or the services must be necessary for the establishment of a safe and effective maintenance program; and
  5. Individual must be medically stable enough to participate in the treatment plan; and
  6. Individual is expected to show measurable functional improvement in a reasonable and generally predictable period of time; and
  7. Individual requires the judgment, knowledge and skills of a licensed therapist; and
  8. Therapy includes a discharge plan.

Examples of Skilled Services include, but are not limited to, the following:

Note:

Not Medically Necessary:

Outpatient skilled nursing services are considered not medically necessary when the criteria above are not met.

Outpatient skilled rehabilitation services are considered not medically necessary when the criteria above are not met.

Coding

Coding edits for medical necessity review are not implemented for this guideline. Where a more specific policy or guideline exists, that document will take precedence and may include specific coding edits and/or instructions. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Discussion/General Information

Skilled nursing and skilled rehabilitation services, furnished pursuant to physician orders, require the skills of qualified technical or professional health personnel such as registered nurses, physical therapists, occupational therapists and speech pathologists or audiologists. These services must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the individual and to achieve the medically desired result.

Definition of Custodial Care:

Note: Custodial care may occur in settings other than the home.

References

Peer Reviewed Publications:

  1. Cruise CM, Sasson N, Lee MH. Rehabilitation outcomes in the older adult. Clin Geriatr Med. 2006: 22(2):257-267.
  2. Ensberg M, Gerstenlauer C. Incremental geriatric assessment. Prim Care. 2005; 32(3):619-643.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Publication 100-02. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673. Accessed on June 15, 2021.
History

Status

Date

Action

Reviewed

08/12/2021

Medical Policy & Technology Assessment Committee (MPTAC) review. References section updated.

Reviewed

08/13/2020

MPTAC review. References section updated.

Reviewed

08/22/2019

MPTAC review. References section updated.

Revised

11/08/2018

MPTAC review. Changed “qualified” to “licensed” in medically necessary statement on outpatient skilled rehabilitation services. Description and References sections updated.

Reviewed

02/27/2018

MPTAC review. Updated header language from “Current Effective Date” to “Publish Date. References section updated.

Reviewed

02/02/2017

MPTAC review. Formatting updated in clinical indication section. Discussion and References section updated.

Revised

05/05/2016

MPTAC review. Clarified examples of skilled services in clinical indication section related to insulin injections and feedings. References section updated.

Revised

02/04/2016

MPTAC review. Defined abbreviations in clinical indications section. Reference section updated.

Reviewed

02/05/2015

MPTAC review. Description and References sections updated.

Reviewed

02/13/2014

MPTAC review. References section updated.

Reviewed

02/14/2013

MPTAC review. References section updated.

Reviewed

02/16/2012

MPTAC review. References section updated.

Reviewed

02/17/2011

MPTAC review. Title of Clinical Indication section, Description, Discussion (including definition of custodial care), and Reference links updated. Clarifications made to examples of skilled services.

Reviewed

02/25/2010

MPTAC review. Reference links updated.

Reviewed

02/26/2009

MPTAC review. References and discussion updated. Case management section removed.

Revised

02/21/2008

MPTAC review. Added not medically necessary statements for outpatient skilled nursing services and outpatient skilled rehabilitation services. Minor clarification made to example of skilled services. Description, discussion and references updated. Coding updated to remove specific codes from this definition document.

Reviewed

03/08/2007

MPTAC review. References and coding updated.

Revised

03/23/2006

MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonizatio

Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

 

 

No Policy

Anthem MW

02/11/2005

MA-020

Skilled Nursing Facility Setting, Skilled and Custodial Services Defined

WellPoint Health Networks, Inc.

09/22/2005

Clinical Guideline

Skilled Nursing and Skilled Rehabilitation Services

 

 


Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.

Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

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