Appeal type: Home Health
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve nine home health physical therapy visits. We decided that the 
Plan does not have to pre-approve three home health skilled nursing visits and nine home health aide visits.  
 
You asked the Plan to pre-approve home health services.. You say that the services requested are medically 
necessary. The Plan says that this is not medically necessary. 
 
We decided that the Plan has to pre-approve nine 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 for these services. Our reviewer says that the clinical 
documentation does not specify any new medical concerns, changes in medications or plan of care 
(documented concerns are functional in nature) thus the records do not show that 3 home health skilled nursing 
or 9 home health aide 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 patient'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 the services have been met. Therefore, we decided that the Plan has to pre-
approve nine home health physical therapy visits.  
 
We also decided that the Plan does not have to pre-approve three home health skilled nursing visits and 
nine home health aide 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 these services. Our reviewer says that the clinical 
documentation shows that patient has functional impairments requiring assistance with short distances and 
requires evaluation for medical equipment with home safety evaluation thus the records do show that 9 home 
health skilled 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 
patient'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 three home health skilled nursing visits and nine home health aide visits have 
not been met. Therefore, we decided that the Plan does not have to pre-approve three home health skilled 
nursing visits and nine 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.