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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say to qualify for home health services, the patient must be: 

1. Confined to the home; 
2. Under the care of a physician or allowed practitioner; 
3. Receiving services under a plan of care established and reviewed by a physician; 
4. Be in need of (a) skilled nursing care on an intermittent basis, (b) physical therapy, (c) speech therapy or (d) continuing occupational therapy. 

You can find this rule at 42 CFR Section 409.42. 

The rules say that eligibility for the home health benefit will be determined based on the certifying physician or allowed practitioner's records. If the enrollee was directly admitted to home health from an acute or post-acute care facility, the facility records may be used instead. The medical records for the enrollee must contain information that justifies the referral for home health services. 

The certifying physician or allowed practitioner must document that there was a face-to-face encounter with the enrollee within the required timeframe. The records must contain the actual clinical note for the face-to-face encounter visit. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 7, Section 30.5.1, 30.5.1.1, and 30.5.1.2. 

The rules say that physical therapy (PT) Evaluation and PT Re-evaluation 

Evaluation is a comprehensive service that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities. Evaluation is warranted at the start of therapy or when the beneficiary's condition changes or treatment needs change so as to potentially warrant a new plan of care or a change to an existing plan of care. The time spent in evaluation does not count as treatment time.

1. The initial examination has the following components: 

a. The patient history to include prior level of function, 

b. Relevant systems review, 

c. Tests and measures, 

d. Current functional status (abilities and deficits), and 

e. Evaluation of patient's, physician's and as appropriate the caregiver's goals 

2. Factors that influence the complexity of the examination and evaluation process include the clinical findings, extent and duration of loss of function, prior functional level, social/environmental considerations, educational level, the patient's overall physical and cognitive health status, social/cultural supports, psychosocial factors and use of adaptive equipment. Thus, the evaluation reflects the chronicity or severity of the current problem, the possibility of multi-site or multi-system involvement, the presence of preexisting systemic conditions or diseases, and the stability of the condition. Physical therapists also consider the level of the current impairments and the probability of prolonged impairment, functional limitation, the living environment, prior level of function, the social/cultural supports, psychosocial factors, and use of adaptive equipment. 

3. Initial evaluations or re-evaluations may be determined reasonable and necessary even when the evaluation determines that skilled rehabilitation is not required if the patient's condition showed a need for an evaluation, or even if the goals established by the plan of treatment are not realized. 

4. Re-evaluation is considered reasonable and necessary when the beneficiary's condition changes or treatment needs change so as to potentially warrant a new plan of care or a change to an existing plan of care. Some regulations and state practice acts require reevaluation at specific intervals. 

5. Re-evaluations are appropriate periodically to assess progress toward goals established in the plan of treatment, or to identify and establish interventions for newly developed impairments at least once every 30 days, for each therapy discipline. 

You can find this information in Medicare's Local Coverage Determination (LCD): Home Health Physical Therapy (L34564).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.