Appeal type: Home Health
Decision: Partially Favorable

We decided that the Plan has to pre-approve the OT evaluation. We decided that the Plan does not have to pre-
approve three social worker visits. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan says that 
the services are not medically necessary. 
 
We decided that the Plan has to pre-approve the OT evaluation. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 these services. Our reviewer says that 
the OT evaluation is medically necessary and the social worker visits are not medically necessary. Our 
physician reviewer found the enrollee is noted to have multiple sclerosis. It is unclear what services a social 
worker would provide, given that the enrollee already has a health care provider and live-in aide. An OT 
evaluation is reasonable and medically necessary to see if any equipment or equipment upgrades are required to 
make activities of daily living easier for the enrollee and caregiver. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the OT evaluation have been met. Therefore, we decided that the Plan has to 
pre-approve the OT evaluation.  
 
We also decided that the Plan does not have to pre-approve three social worker visits. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 these services. Our reviewer says that 
the OT evaluation is medically necessary and the social worker visits are not medically necessary. Our 
physician reviewer found the enrollee is noted to have multiple sclerosis. It is unclear what services a social 
worker would provide, given that the enrollee already has a health care provider and live-in aide. An OT 
evaluation is reasonable and medically necessary to see if any equipment or equipment upgrades are required to 
make activities of daily living easier for the enrollee and caregiver. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the three social worker visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve three social worker visits.. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.