HNS Policy 

Maximum medical improvement (MMI) occurs when a patient with an illness or injury reaches a state where additional, objective, measurable improvement cannot reasonably be expected from additional treatment, and/or when a treatment plateau in a person's healing process is reached. 

HNS requires re-exams approximately every 4 weeks or 12 visits (whichever comes first) in order to evaluate the effectiveness of treatment, to determine whether MMI has been reached, and to determine the appropriateness of additional care.

Clinical examination findings must objectively substantiate the medical necessity of the services provided and those services must be consistent with the patient’s chief complaint, the objective exam findings, diagnoses and treatment plan (Exception: maintenance care).

The re-exam should include such relevant tests to objectively evaluate the patient’s progress.

In order to make a valid and reliable determination of meaningful progress toward treatment goals, and whether maximum medical improvement has been reached, it is essential that the patient record include relevant standardized outcome assessments.

HNS Policies: 

HNS requires the use of outcome assessment tools (and other objective tests, as applicable) as part of the initial examination to establish a baseline, and at each re-exam to evaluate the effectiveness of treatment, to determine the appropriateness of additional care, and to determine when MMI has been reached (or not reached).

Documentation in the health care record must include evidence the patient’s progress was objectively measured against the objective goals of the treatment plan at each re-exam. The clinical record must clearly indicate if and when MMI has been reached.

Once MMI has been reached the patient should be discharged, referred or switched to maintenance/supportive care.  The cost of maintenance/supportive care is the responsibility of the member, not the health care plan. (Exception: If maintenance/supportive care is covered by the health care plan.)