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.