Section 554.2401 - General Qualifications for Medical Necessity DeterminationsMedical necessity is the prerequisite for participation in the Medicaid (Title XIX) Long-term Care program. This section contains the general qualifications for a medical necessity determination. To verify that medical necessity exists, an individual must meet the conditions described in paragraphs (1) and (2) of this section.
(1) The individual must demonstrate a medical condition that: (A) is of sufficient seriousness that the individual's needs exceed the routine care which may be given by an untrained person; and(B) requires licensed nurses' supervision, assessment, planning, and intervention that are available only in an institution.(2) The individual must require medical or nursing services that: (A) are ordered by a physician;(B) are dependent upon the individual's documented medical conditions;(C) require the skills of a registered or licensed vocational nurse;(D) are provided either directly by or under the supervision of a licensed nurse in an institutional setting; and(E) are required on a regular basis.26 Tex. Admin. Code § 554.2401
The provisions of this §19.2401 adopted to be effective September 1, 2008, 33 TexReg 7264; Entire chapter transferred from Title 40, Pt. 1, Ch. 19 by Texas Register, Volume 45, Number 50, December 11, 2020, TexReg 8871, eff. 1/15/2021