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Corporate

Medically Necessary and Reasonable

Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7 §20.1)External PDF

All services billed to Medicare must meet the criteria of "medically necessary and reasonable." To determine whether a service is reasonable and necessary, the Medicare home health benefit considers each beneficiary's unique medical condition. The medical record documentation, including the Plan of Care and Outcome and ASsessment Information Set (OASIS), provide the basis for this determination. Coverage decisions are always based upon the objective clinical evidence of the beneficiary's individual need for care.

  • It is the home health agency's responsibility to provide clear documentation of the medical necessity and reasonableness. This includes: progress or lack of progress, medical condition, functional losses, and treatment goals.
  • The length of time services will be covered is generally determined by the beneficiary's needs.

Impact of Caregivers on Medical Necessity

National and Local Coverage Determinations

Documenting Medical Necessity

Updated: 12.19.16


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