Appeal type: Home Health
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 5 additional home health skilled nursing visits. We decided that 
the Plan does not have to pre-approve an additional 5 home health physical therapy visits.  
 
You asked the Plan to pre-approve home health physical therapy (G0151 x5) and home health skilled nursing 
(G0299 x5). You say that the services are medically necessary. The Plan says that the services are not 
medically necessary. 
 
We decided that the Plan has to pre-approve 5 additional home health skilled nursing visits.  
 
The Plan follows 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 the item/service at issue. Our reviewer 
says that the service is medically necessary. Our physician reviewer found that clinical documentation specifies 
an acute clinical status change with medication changes and edema management with appropriate home health 
skilled nursing goals. The records do show that 5 additional home health skilled nursing visits are required to 
effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to 
establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. 
 
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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pre-approve 5 additional home health skilled nursing visits.  
 
We also decided that the Plan does not have to pre-approve an additional 5 home health physical therapy 
visits. 
 
The Plan follows Medicare rules. Medicare 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 the item/service at issue. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found that the clinical documentation 
by provider does not reference an acute functional status change. The records do not show that 5 additional 
home health skilled physical therapy visits are required to effectively provide treatment, care, and/or services in 
order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the 
enrollee's level of function and/or prevent deterioration.   
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 item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional 5 home health physical therapy 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.