Appeal type: Home Health
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 6 additional home health PT visits (G0151). We decided that the 
Plan does not have to pre-approve 12 home health skilled nursing services visits (G0299).  
 
You asked the Plan to pre-approve six (6) additional home health physical therapy (PT) visits (G0151) and 
twelve (12) home health skilled nursing services visits (G0299). You say that you disagree with the denial. The 
Plan says that the enrollee's level of function no longer requires the intervention of skilled therapists. Home 
exercise program has been reinforced. Ongoing home health services are no longer required as of May 1, 2023. 
 
We decided that the Plan has to pre-approve 6 additional home health PT visits (G0151). 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 for 6 additional home health PT visits. Our reviewer 
says that the services are medically reasonable and necessary. Our physician reviewer found clinical 
documentation shows that the enrollees prior initial clinical event (SDH) was modified independent. Currently 
the enrollee is mod to total assist with mobility tasks, per last PTA note, enrollee has been making progress in 
activity tolerance, accuracy and in sitting balance. It is also noted that the enrollee has grade 3 muscle tone 
(spasticity) thus 6 additional home health PT sessions would be medically necessary. Skilled physical therapy 
is an effective treatment for spasticity and for neurorehabilitation following SDH. Documentation shows that 
the enrollee is home-bound and making progress with physical therapy. Therefore, we decided that the Plan has 
to pre-approve 6 additional home health PT visits.  
 
We also decided that the Plan does not have to pre-approve 12 home health skilled nursing services 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 for 12 home health skilled nursing 
services visits. Our reviewer says that the services are not medically reasonable and necessary. Our physician 
reviewer found clinical documentation does not show any acute clinical changes, complex wounds, medication 
changes, thus, 12 additional home health skilled nursing visits are not medically necessary. Therefore, we 
decided that the Plan does not have to pre-approve 12 home health skilled nursing services 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.