Medical 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. (1) The individual must demonstrate a medical condition that:

   1. (A) is of sufficient seriousness that the individual's needs exceed the routine care which may be given by an untrained person; and
   2. (B) requires licensed nurses' supervision, assessment, planning, and intervention that are available only in an institution.

2. (2) The individual must require medical or nursing services that:

   1. (A) are ordered by a physician;
   2. (B) are dependent upon the individual's documented medical conditions;
   3. (C) require the skills of a registered or licensed vocational nurse;
   4. (D) are provided either directly by or under the supervision of a licensed nurse in an institutional setting; and
   5. (E) are required on a regular basis.

Source Note:The provisions of this §554.2401 adopted to be effective September 1, 2008, 33 TexReg 7264; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871.