Case Review Criteria for Comprehensive Outpatient Rehabilitation Facility (CORF)

Medicare Quality Improvement Organization (QIO) review of a termination of service appeal focuses on the medical necessity of the services being rendered and the appropriateness of the setting. The information included in this section can be found in the Outpatient Physical Therapy, Comprehensive Outpatient Rehabilitation Facility, and Community Mental Health Center Manual and serves as a general guideline for Medicare QIO appeal determinations. A decision as to whether or not care should be covered by Medicare must be made based on thorough analysis of the patient's condition and individualized need for care.

Prohibition Against Use of “Rules of Thumb” in Medicare Case Review Determinations

Do not notify patients that services are not covered by Medicare because of “rules of thumb,” such as lack of restoration potential, ability to walk a specific distance, degree of stability, or because of general inferences about patients with similar diagnoses or general data related to utilization.

Chapter II, Sections 251, 253, 270, 271, 272, and 273, Centers for Medicare & Medicaid Services.
Available online at http://cms.hhs.gov/manuals/PBM/list.asp

Resources Related to Medicare Payment and Coverage Guidelines

Termination of service appeal review focuses on the medical necessity of the services being rendered and the appropriateness of the setting. For comprehensive outpatient rehabilitation facility, home health agency, hospice and skilled nursing facility, the following listing should be used as a reference.

Comprehensive Outpatient Rehabilitation Facility

Excerpts from the Centers for Medicaid and Medicare Services (CMS) Comprehensive Outpatient Rehabilitation Facility and Community Mental Health Center Manual.

• Section 251.    Covered/Non-covered CORF Services
• Section 253.    Specific CORF Services
• Section 270.    Conditions for Coverage of Outpatient Physical Therapy, Occupational Therapy and Speech Pathology Services
• Section 271.    Physical Therapy Services
• Section 272.    Speech Pathology Services
• Section 273.    Occupational Therapy Services

Home Health Agency (HHA)

Excerpts from the CMS Home Health Agency Manual

• Section 203.    Conditions to be Met for Coverage of Home Health Services
• Section 204.    Conditions the Patient Must Meet to Qualify for Coverage of Home Health Services
• Section 205.    Coverage of Services Which Establish Home Health Eligibility
• Section 206.    Coverage of Other Home Health Services
• Section 215.    Duration of Home Health Services

Hospice

Excerpts from the CMS Hospice Manual

• Section 230. Requirements for Coverage

Skilled Nursing Facility (SNF)

Excerpts from the CMS Skilled Nursing Facility Manual

• Section 214.    Covered Level of Care — General
• Section 230.    Covered Extended Care Services