Appeal type: Home Health
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 4 home health physical therapy visits. We decided that the Plan 
does not have to pre-approve 9 home health skilled nursing visits.  
 
You asked the Plan to pre-approve home health physical therapy (G0151 x4) and home health skilled nursing 
(G0299 x9). You say that this is medically necessary. The Plan says that the services are not medically 
reasonable and necessary. 
 
We decided that the Plan has to pre-approve 4 home health physical therapy 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 4 home health physical therapy visits. 
Our reviewer says that the services are medically reasonable and necessary. Our physician reviewer found that 
the clinical documentation shows that the enrollee had a neurodegenerative disease and unmet appropriate 
home health physical therapy goals (gait distance, get up and go/balance tests scores with further medical 
equipment evaluation). The records show that 4 additional home health 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 4 home health physical therapy visits have been met. Therefore, we decided that 
the Plan has to pre-approve 4 home health physical therapy visits.  
 
We also decided that the Plan does not have to pre-approve 9 home health 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 4 home health physical therapy visits. 
Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer found 
that the clinical documentation does not specify any acute clinical status, medication or plan of care change, or 
complex wound care needed. The records do not show that 9 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 9 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 9 home health skilled nursing 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.