Appeal type: Home Health
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 4 of the 7 requested home health PT visits. We decided that the 
Plan does not have to pre-approve the 4 skilled nursing visits and 3 additional home health PT visits.  
 
You asked the Plan to pre-approve 4 skilled nursing visits and 7 physical therapy (PT) visits. You say that the 
services are medically necessary. The plan denied your request. The Plan says that the services are not 
medically necessary. 
 
We decided that the Plan has to pre-approve 4 of the 7 requested home health PT 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 home health care services. Our 
reviewer says that 4 of the 7 requested home health PT visits are medically necessary. Our physician reviewer 
found the enrollee was previously modified independent with mobility and performing transfers. The enrollee 
would benefit from 4 visits of home health physical therapy to make further progress and transition to a home 
exercise program. 
 
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 additional home health PT visits have been met. 
 
We also decided that the Plan does not have to pre-approve the 4 skilled nursing visits and 3 additional 
home health PT 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 home health care. Our reviewer says 
that the services beyond 4 additional home health PT visits are not medically necessary. Our physician 
reviewer found the enrollee is noted to have stable vital signs. The enrollee does not require wound care, 
catheterization, G-tube feeding, or administration of intravenous or complex medications. The enrollee has 
been educated in terms of medication management. The enrollee is receiving routine foot care that does not 
require skilled nursing care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health care have not been met. 
 
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.