Appeal type: Home Health
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 8 skilled nursing visits. We decided that the Plan does not have to 
pre-approve 8 additional skilled nursing visits.  
 
You asked the Plan to pre-approve 16 additional skilled nursing visits. You say that the enrollee is receiving 
wound care every other day. You also say that they enrollee lives alone and cannot perform this wound care on 
their own. The Plan denied your request. The Plan says additional visits are not medically necessary. 
 
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 decided that the Plan has to pre-approve 8 skilled nursing 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 16 additional skilled nursing visits. Our 
reviewer says that 8 additional skilled nursing visits are medically necessary. Our physician reviewer found 
that since the enrollee requires wound care every other day, then 30 skilled nursing visits would be required 
(3.5 x 8.5 = 29.75) over an 8.5 week period. The reviewer found that because the enrollee is receiving wound 
care at the wound clinic once every two weeks, the enrollee only requires 2 skilled nursing visits (29.75  4 = 
25.75).  The record shows that the plan has approved 18 visits over 8.5 weeks. This number should be 
increased to 26 visits and the 8 additionally requested visits should remain denied.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 16 additional skilled nursing visits have been met Therefore, we decided that 
the Plan has to pre-approve 8 skilled nursing visits.  
 
We also decided that the Plan does not have to pre-approve 8 additional skilled nursing visits. 
 
Our reviewer says that 8 additional skilled nursing visits are not medically necessary. Our physician reviewer 
found that the enrollee requires 26 skilled nursing visits. The reviewer found that the remaining 8 visits 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 16 additional skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 8 additional 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.