Appeal type: Home Health
Decision: Partially Favorable

We decided that the Plan has to pre-approve 7 additional home health PT visits and 8 additional home health OT visits. We decided that the Plan does not have to pre-approve 3 additional SN visits.
You asked the Plan to pre-approve 7 additional home health PT visits and 8 additional home health OT visits. You say that the 7 additional home health PT visits, 8 additional home health OT visits, and 3 additional SN visits are medically necessary. The Plan says that the 7 additional home health PT visits, 8 additional home health OT visits, and 3 additional SN visits are not medically necessary.
We decided that the Plan has to pre-approve 7 additional home health PT visits and 8 additional home health OT visits.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 7 additional home health PT visits and 8 additional home health OT visits. Our reviewer says that the 7 additional home health PT visits and the 8 additional home health OT visits are medically necessary. Our physician reviewer found the member has a relevant past medical history that includes diabetes, hypertension, stroke, asthma, osteoarthritis of both knees, and severe paralysis related to gunshot wound to the head in 1972. DME includes a wheelchair, Hoyer lift, and sliding board. The member lives with her spouse and also has caregiver assistance. She had been able to assist with transfers but fell. Currently she requires maximum assistance for transfers. She is being transferred into a wheelchair using a lift and is up for 10-12 hours/day. She was evaluated for occupational therapy. She required maximum assistance for upper body dressing, grooming, and oral hygiene. She was at a dependent level of function for lower body dressing and toileting. When evaluated for physical therapy she was eager to progress back to being able to perform transfers and low-level gait. She required assistance x2 when being transferred using a Hoyer lift. There were no complaints of pain. She reported that she had not been up all weekend or compliant with her home exercise program. She was educated in terms of taking her blood pressure daily and blood sugar as often as had been prescribed. She needed help with both due to her stroke. Her husband verbalized understanding. A medication planner was set up. The member requires assistance of more than 1 person for performing essential activities of daily living such as transfers. She had previously been able to assist with transfers and had limited ambulatory capacity supporting the expectation that her condition will improve within a reasonable and predictable period of time. Her condition would be expected to decline without the requested therapy services being requested. The additional physical therapy and occupational therapy services are medically necessary for treating her condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 7 additional home health PT visits and 8 additional home health OT visits have been met. Therefore, we decided that the Plan has to pre-approve 7 additional home health PT visits and 8 additional home health OT visits.
We also decided that the Plan does not have to pre-approve 3 additional SN visits.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 3 additional SN visits. Our reviewer says that the 3 additional SN visits are not medically necessary. Our physician reviewer found there are no wound care needs or unaddressed medical issues. Education has been first provided in terms of managing her hypertension and diabetes and she has caregiver assistance available for processing information and providing assistance. Ongoing skilled nursing services are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3 additional SN visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 3 additional SN visits.