The Enigma of Medical Necessity (Part 2 of 2)

In practice, a determination of need for long term care (MDS) is completed when a patient enters a Medicaid long-term care facility. A registered Nurse must sign and certify that the MDS has been properly completed. The completed MDS form is submitted to the State contractor that handles this issue (TMHP). TMHP then uses the MDS to determine if the patient meets medical necessity for Medicaid long-term care benefits.

The Nursing Facility Requirements for Licensure and Medicaid Certification Handbook (“NF Handbook”) details the conditions used to verify the existence of medical necessity as follows:

Patient must demonstrate a medical condition that (A) is seriousness enough to exceed the routine care that an untrained person can give, and (B) requires the skills of a licensed nurse (supervision, assessment, planning and intervention) that are only available in an institution; AND,

Patient must require medical or nursing services (A) ordered by a physician, (B) based on documented medical condition, (C) requiring       a nurse (RN of LVN), (D) provided in an institutional setting by, or supervised by, a nurse, (E) and required on a regular basis. (Paraphrased from NF Handbook Sec. 19.2401).

This is the standard that TMHP should use in evaluating the MDS and determining Medical Necessity. If a denial of medical necessity is made, the nursing home is given the opportunity to present additional information concerning the patient’s medical condition and need for care. This “appeal” of the denial must be made by the nursing home within 10 days of receipt of the denial. When the findings are contested within the 10 days, a TMHP physician must review the case. If that physician finds no medical necessity, then the finding is final and the Medicaid applicant is notified. Once the Medicaid applicant is notified, the applicant has 90 days in which to appeal the decision by requesting a fair hearing with HHSC.

Scroll to top