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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say to qualify for home health services, the patient must be: 
1. Confined to the home; 
2. Under the care of a physician or allowed practitioner; 
3. Receiving services under a plan of care established and reviewed by a physician; 
4. Be in need of (a) skilled nursing care on an intermittent basis, (b) physical therapy, (c) speech therapy or (d) continuing occupational therapy. 
You can find this rule at 42 CFR Section 409.42. 

The rules say that eligibility for the home health benefit will be determined based on the certifying physician or allowed practitioner's records. If the enrollee was directly admitted to home health from an acute or post-acute care facility, the facility records may be used instead. The medical records for the enrollee must contain information that justifies the referral for home health services.

The certifying physician or allowed practitioner must document that there was a face-to-face encounter with the enrollee within the required timeframe. The records must contain the actual clinical note for the face-to-face encounter visit. You can find these rules in the Medicare Benefit Policy Manual, Chapter 7, Section 30.5.1, 30.5.1.1, and 30.5.1.2. 

The rules say that Although rehabilitative services are provided by physical therapy (PT), speech therapy (ST) and occupational therapy (OT), this policy only addresses OT. 

OT is an integral component of rehabilitative services in the areas of physical, cognitive and psychosocial impairment. OT is based on purposeful, goal directed activity (occupation). The goal of OT is to prevent, improve or restore physical and/or cognitive impairment following disease or injury. 

Occupational therapists utilize clinical history, observation, interview, standardized testing and assessment of activities of daily living (ADLs) skills, work skills and leisure skills to characterize individuals with impairments, functional limitations and disabilities. The results of these assessments are used to identify structural impairments and functional limitations and to design an individualized plan of treatment to assist in improving or restoring function. All OT services must be performed by or under the supervision of a skilled qualified occupational therapist.

1. The treatment approach includes: 
a. Evaluation 
b. Basic activities of daily living (BADLs) training 
c. Instrumental activities of daily living (IADLs) training 
d. Muscle re-education 
e. Cognitive training 
f. Perceptual motor training 
g. Fine motor coordination/strengthening/coordination 
h. Orthotics (splinting) 
i. Adaptive equipment fabrication and training j. Environment modification recommendations/training 
k. Patient/caregiver education/training
l. Transfer training 
m. Functional mobility training 
n. Manual therapy 
o. Physical agent modalities 
p. Neurodevelopment training

2. Coverage of skilled rehabilitation services is contingent upon the beneficiary's need for skilled care whether the goal of therapy includes maintenance or improvement. 

3. The pressing need for a service, or the lack of availability of unskilled personnel to render the service with the necessary frequency does not itself make a service skilled. However, some services that would not normally be considered skilled therapy may require the skilled services of a therapy professional because of a special complicating medical factor. This must be clearly evident in the medical record. 

4. OT is only covered when it is rendered under a written plan of treatment established by the physician and the qualified occupational therapist, and signed (including professional identity) and dated by the physician. The plan of treatment should contain, at a minimum, all diagnoses, long term treatment goals and type, amount, duration and frequency of therapy services. The physician should review the plan of treatment every 60 days. 

5. The physician and/or therapist must document the patient's functional limitations in terms that are objective and measurable. 

6. Rehabilitation services for vision impairment: Medicare beneficiaries who are blind or visually impaired are eligible for physician prescribed rehabilitation services on the same basis as beneficiaries with other medical conditions.

Maintenance Therapy 

Coverage of skilled rehabilitation services is contingent upon a beneficiary's need for skilled care. 

When a program to maintain or reduce decline in functional status requires the skills of a licensed therapist to be performed safely and effectively, provision of skilled services for the execution of that therapy program is covered. The skilled need must come from the nature of the service being rendered and the patient's unique circumstance. The provision of therapy services by skilled therapy personnel does not itself make the service one that requires skilled care. 

You can find this information in Medicare's Local Coverage Determination (LCD): Home Health Occupational Therapy (L34560).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.