Case Review Criteria For Skilled Nursing Facility (SNF)

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 may be found in the Skilled Nursing Facility Manual* and serves as a general guideline for Medicare QIO appeal determinations. A decision as to whether or not services 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 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, Section 214 and 230, Centers for Medicare & Medicaid Services. Available online at http://cms.hhs.gov/manuals/PBM/list.asp

Basic Information Related to Covered and Non-Covered SNF Services
Determining Whether A Service is Skilled
“Daily” Skilled Service
Appropriateness of Setting
Management and Evaluation of a Patient Care Plan
Observation and Assessment of Patient's Condition
Teaching Activities
Direct Skilled Nursing
Skilled Physical Therapy
Skilled Speech Therapy
Skilled Occupational Therapy
Non-Skilled Services