Appeal type: Home Health
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 7 home health physical therapy visits and 7 home health 
occupational therapy visits. We decided that the Plan does not have to pre-approve 5 home health skilled 
nursing visits and 5 home health aide visits.  
 
You asked the Plan to pre-approve 5 home health skilled nursing visits, 7 home health physical therapy visits, 7 
home health occupational therapy visits and 5 home health aide visits. You say that the services are necessary. 
The Plan says that based on the documentation provided, coverage criteria have not been met. 
 
We decided that the Plan has to pre-approve 7 home health physical therapy visits and 7 home health 
occupational therapy visits.  
 
The Plan follows Medicare rules. Medicare rules say that home healthcare services are covered when specific 
criteria are met. 
 
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 7 home health physical therapy visits 
and 7 home health occupational therapy visits. Our reviewer says that the services are medically necessary. Our 
physician reviewer found clinical documentation shows that the enrollee has a neurodegenerative disease with 
progression of visual spatial, fine motor and speech/cognitive deficits with appropriate unmet mobility and self 
care skilled therapy goals (house adaptations, adaptive equipment and treatment goals) that would require the 
clinical experience of skilled therapists. Thus, the records do show that 7 additional physical and 
occupational 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 7 home health physical therapy visits and 7 home health occupational therapy 
visits have been met. Therefore, we decided that the Plan has to pre-approve 7 home health physical therapy 
visits and 7 home health occupational therapy visits.  
 
We also decided that the Plan does not have to pre-approve 5 home health skilled nursing visits and 5 
home health aide visits. 
 
The Plan follows Medicare rules. Medicare rules say that home healthcare services are covered when specific 
criteria are met.  
 
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 5 home health skilled nursing visits and 
5 home health aide visits. Our reviewer says that the services are not medically necessary. Our physician 
reviewer found clinical documentation does not specify any change in plan of care, medications, complex 
wounds or acute clinical status changes. Thus, the records do not 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. Clinical documentation does not specify any plan of care requiring home health aide 
services thus 5 additional home health aide visits are not reasonable and necessary to the treatment of the 
enrollees illness or injury by the skilled professional staff. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 5 home health skilled nursing visits and 5 home health aide visits have not been 
met. Therefore, we decided that the Plan does not have to pre-approve 5 home health skilled nursing visits and 
5 home health aide 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.