The Social Security Act provision limiting Medicare coverage to medically necessary services and supplies uses broad language to reference this highly important coverage variable. Specifically, Section 1862(a)(1)(A) of the Social Security Act states the following:
“Notwithstanding any other provision of this title, no payment may be made under part A or part B for any expenses incurred for items or services;(1)(A) which, except for items and services described in a succeeding subparagraph, are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”
Of course, CMS uses a number of local medical review policies, local coverage determinations and national coverage determinations to assess the appropriateness of care. Further, medically eligible code pair edits and standards of care assure that claims can be handled on an automated basis without extensive post treatment medical review.
However, geriatric patient have unique treatment challenges which do not always fall neatly into the Medicare medical necessity definition. The following factors can complicate medical decisions related to geriatric care:
- Age-related comorbidities complicating patient self-care
- Lack of adequate family or other support at home
- Limitations or inability of patient to adequately detect and report pertinent medical information
- Need to discuss patient care and pharmacopoeia management with caregiver
- Temporary, heightened anxiety over recent medical episodes
- Patient education complexities attributable to the patient’s functional or cognitive limits and the need to customize instruction and assess patient’s capacity for follow-through
Appeals for lack of medical necessity of in-patient care should reference any relevant documented information related to the above factors.
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