Determination of Medical Necessity of Rehabilitation Therapy Services

Medicare defines medical necessity as a determination that a service is reasonable and necessary for the diagnosis or treatment of illness or injury. However, the use of this term in health care settings is controversial and often confusing. Applying the concept of medical necessity to rehabilitation therapy services is challenging for several reasons. The issue of the medical necessity of therapy services presents many questions and challenges for post-acute and long-term care (PALTC) medical directors, attending physicians, and patients. This manual is designed to help medical directors and attending physicians determine medical necessity and identify the appropriate use of therapy services. Physicians will appreciate guidance about the appropriateness and potential benefits of therapy services and the ability of individuals in the PALTC setting to tolerate these services. The manual defines common abbreviations and therapy services, has a glossary of terms, FAQs, and sample procedures and forms.