Appeal type: Home Health
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the 4 additional PT visits. We decided that the Plan does not 
have to pre-approve the 4 additional home health skilled nursing visits.  
 
You asked the Plan to pre-approve 4 additional home health physical therapy (PT) visits and 4 home health 
skilled nursing visits. You say that you would like to request reconsideration of the denied home health 
services, and that the services requested are medically necessary. The Plan says that only two additional PT 
visits are sufficient to meet the patient's needs.  
 
We decided that the Plan has to pre-approve the 4 additional 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 the 4 additional PT visits. Our reviewer 
says that the requested additional PT services are shown to be reasonable and necessary; however, additional 
skilled nursing visits are not. Our physician reviewer found the clinical documentation shows that patient's past 
level of function was modified independent with mobility and self-care tasks, and the patient is currently 
requiring minimal assist with ambulation, transfers and bed mobility. Pain management and medical equipment 
evaluation in relation to spinal stenosis with reasonable home health physical therapy goals are not met; thus, 
the records do show that 4 additional 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 the 4 additional PT visits have been met. Therefore, we decided that the Plan 
has to pre-approve the 4 additional PT visits.  
 
We also decided that the Plan does not have to pre-approve the 4 additional home health skilled nursing 
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 the 4 additional home health skilled 
nursing visits. Our reviewer says that the requested additional PT services are shown to be reasonable and 
necessary; however, additional skilled nursing visits are not. Our physician reviewer found the clinical 
documentation does not specify any plan of care or medication changes. Clinical documentation does not show 
any acute clinical status changes; thus, the records do show that 4 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 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 4 additional home health skilled nursing visits have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the 4 additional home health skilled nursing 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.