MEDICAL NECESSITY
Medical necessity is met when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgement, knowledge, and skills of an RN or when allowed an LVN are necessary to improve the condition or prevent or slow further deterioration. The needed services must be of such a complexity that the skills of an RN or LVN are required to furnish them. Services shall cease to be covered when the individualized assessment does not demonstrate a necessity for skilled services or if they can be safely and effectively performed by the patient or unskilled caregivers.
Some services are considered a skilled service based on complexity such as intravenous and intramuscular injections and the insertion of catheters. A service that, by its nature, requires a skilled clinician to be performed continues to be a covered skilled service even if taught to the family or caregivers.
Skilled services ordered must be reasonable and necessary and consistent with the treatment of the primary diagnosis and the reason for referral. They must conform with the nature and severity of the illness, the patient’s needs, and accepted medical and nursing standards.
Under certain circumstances, the evaluating RN/Therapist can provide supportive documentation from the home assessment to support the medical necessity for the home health needs. The physician would be required to sign these documents and retain a copy in their office as part of the patient’s medical records.
