La. Admin. Code tit. 50 § XIII-301
Current through Register Vol. 50, No. 12, December 20, 2024
Section XIII-301 - General Provisions [Formerly LAC 50:XIX.301]A. Medical necessity for home health services is determined by the recipient's illness and/or injury and functional limitations. All home health services shall be medically reasonable and appropriate. To be considered medically reasonable and appropriate, the care must be necessary to prevent further deterioration of a recipient's condition regardless of whether the illness or injury is acute, chronic or terminal. The services must be reasonably determined to: 1. diagnose, cure, correct or ameliorate defects, physical and mental illnesses, and diagnosed conditions of the effects of such conditions; or2. prevent the worsening of conditions, or the effects of conditions, that: a. endanger life or cause pain;b. result in illness or infirmity; orc. have caused, or threatened to cause, a physical or mental dysfunction, impairment, disability, or developmental delay; or3. effectively reduce the level of direct medical supervision required or reduce the level of medical care or services received in an inpatient or residential care setting; or4. restore or improve physical or mental functionality, including developmental functioning, lost or delayed as the result of an illness, injury, or other diagnosed condition or the effects of the illness, injury or condition; or5. provide assistance in gaining access to needed medical, social, educational and other services required to diagnose, treat, or support a diagnosed condition or the effects of the condition, in order that the recipient might attain or retain: f. integration into all natural family, community, and facility environments and activities.B. Home health skilled nursing and aide services are considered medically reasonable and appropriate when the recipients medical condition and medical records accurately justify the medical necessity for services to be provided in their residential setting or any setting in which normal life activities take place, other than a hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities or any setting in which payment is, or could be made, under Medicaid for inpatient services that include room and board rather than in a physicians office, clinic, or other outpatient setting according to guidelines as stated in this Subpart.C. Home health services are appropriate when a recipient's illness, injury, or disability causes significant medical hardship and would interfere with the effectiveness of the treatment if he/she had to go to a physician's office, clinic, or other outpatient setting for the needed service. Any statement on the plan of care regarding this medical hardship must be supported by the totality of the recipient's medical records.D. The following circumstances are not considerations when determining medical necessity for home health services: a. inconvenience to the recipient or the recipient's family;b. lack of personal transportation; orc. failure or lack of cooperation by a recipient or a recipient's legal guardians or caretakers to obtain the required medical services in an outpatient setting.E. Home health services will be authorized upon medical necessity determination based on the states medical necessity criteria pursuant to LAC 50:I.1101.La. Admin. Code tit. 50, § XIII-301
Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 30:431 (March 2004), Amended by the Department of Health, Bureau of Health Services Financing, LR 4459 (1/1/2018).AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.