Appeal type: Home Health
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve seven home health physical therapy visits (G0151). We also 
decided that the Plan does not have to pre-approve nine home health skilled nursing visits (G0299) and ten 
home health occupational therapy visits (G0152).  
 
You asked the Plan to pre-approve home health services. You say that the requested home health services are 
medically necessary. The Plan denied your request. The Plan says that the services 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 seven home health physical therapy visits (G0151).  
 
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 home health physical therapy visits. 
Our reviewer says that home physical therapy is medically necessary. Our physician reviewer found that the 
clinical documentation shows that the enrollee is home bound, still beneath previous functional level with 
functional impairments, and not all appropriate skilled therapy goals with mobility have been met thus the 
records do show that home health skilled physical therapy services 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 home health physical therapy visits have been met. Therefore, we decided 
that the Plan has to pre-approve seven home health physical therapy visits (G0151).  
 
We also decided that the Plan does not have to pre-approve nine home health skilled nursing visits 
(G0299) and ten home health occupational therapy visits (G0152). 
 
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 home skilled nursing visits and 
home occupational therapy visits. Our reviewer says that these services are not medically necessary. Our 
physician reviewer found that the clinical documentation does not specify any acute clinical concerns or status 
changes. The record does not specify any changes in plan of care or medication changes thus the records do not 
show that home health skilled nursing services are required to effectively provide treatment, care, and/or 
services to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the 
enrollee's condition and/or prevent deterioration. The clinical documentation shows that the enrollee previously 
required assistance with some activities of daily living thus the enrollees occupational therapy goals are 
unclear. The records do not show that home health skilled occupational therapy services are required. 
 
 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 home skilled nursing visits and home occupational therapy visits have not 
been met. Therefore, we decided that the Plan does not have to pre-approve nine home health skilled nursing 
visits (G0299) and ten home health occupational therapy visits (G0152).  
 
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.