HI 00601.170 Need Satisfied Only by SNF Inpatient Care
In determining whether the care needed by a beneficiary can as a practical matter
only be provided in an SNF on an inpatient basis, consideration is given to the patient's
condition and to the availability and feasibility of using more economical alternative
facilities and services. In determining the availability of alternative facilities
and services, availability of funds to pay for the services furnished by such alternative
facilities is not a factor to be considered. For instance, an individual in need of
daily physical therapy might be able to receive the needed services from the outpatient
department of a nonparticipating hospital. The fact that Medicare reimbursement could
not be made for such services is not a basis for determining that the needed care
could be provided only in an SNF.
However, if the needed therapy is not available in the area in which the patient resides
and the transporting of the individual to the closest facility furnishing such services
would be an excessive physicial hardship it would be appropriate to conclude that
the needed care can as a practical matter only be provided in an SNF. This conclusion
would also follow even though the patient's condition might not be adversely affected,
if it would be more economical or efficient to provide the covered services in the
SNF. For example, if the patient's condition was such that the daily transportation
required the use of an ambulance, it might be more economical to provide the needed
care in an SNF.