Appeal type: Home Health
Decision: Partially Favorable

 
We decided that the Plan has to pay for the home health physical therapy evaluation provided on December 20, 
2021, and the home health skilled nursing evaluation provided on December 22, 2021. We also decided that the 
Plan does not have to pay for ongoing home health services provided from December 23, 2021, to January 12, 
2022. 
  
You asked the Plan to pay for the home health services. You say that the medical records support the need for 
the home health services provided. The Plan denied your request. The Plan says that the services were 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 pay for the home health physical therapy evaluation provided on 
December 20, 2021, and the home health skilled nursing evaluation provided on December 22, 2021.  
 
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 pay for home health services. Our reviewer says that 
the services were medically reasonable and necessary. Our physician reviewer found the evaluations on 
December 20, 2021, and December 22, 2021, were appropriate to assess home safety, durable medical 
equipment needs, and enrollee/caregiver understanding. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these evaluations have been met. Therefore, we decided that the Plan has to pay 
for the home health physical therapy evaluation provided on December 20, 2021, and the home health skilled 
nursing evaluation provided on December 22, 2021.  
 
We also decided that the Plan does not have to pay for ongoing home health services provided from 
December 23, 2021, to January 12, 2022. 
 
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 pay for home health services. Our reviewer says that 
the services are not medically reasonable and necessary. Our physician reviewer found that the initial 
evaluations did not identify a need for ongoing skilled services. As such, additional home health services were 
not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ongoing home health services have not been met. Therefore, we decided that the 
Plan does not have to pay for ongoing home health services provided from December 23, 2021, to January 12, 
2022. 
 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.