Appeal type: Home Health
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve home health skilled nursing care for the monthly changing of the 
Foley catheter. We decided that the Plan does not have to pre-approve frequent skilled nursing.  
 You asked the Plan to pre-approve 18 home health skilled nursing care visits. You say that the enrollee is 
completely paralyzed on the left side of his body, has chronic health issues and has been bedridden for three 
years. You also say that this service is medically necessary.  The Plan says that the enrollee does not meet the 
guidelines based on the records reviewed. The Plan also has confirmed per outreach to the provider, the 
enrollee has been discharged from home health physical therapy and occupational therapy (5 visits each in 
total) on September 26, 2023. 
 
We decided that the Plan has to pre-approve home health skilled nursing care for the monthly changing 
of the Foley catheter.  
 
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 item/service at issue. Our reviewer 
says that these services are partially medically necessary. Our physician reviewer found the enrollee is noted to 
be medically stable and does not require complex wound care, frequent catheterization, G-tube feeding, or 
administration of intravenous or complex medications. The enrollee has been educated regarding their 
medications and they have not recently been hospitalized. The enrollee does require significant assistance with 
mobility and daily activities, but his level of function and mobility has not significantly changed. The enrollee 
requires monthly changing of the Foley catheter. Therefore, the continued home health skilled nursing care is 
medically necessary for monthly changing of the Foley catheter.  
 
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 service at issue have been met. Therefore, we decided that the Plan has to 
pre-approve home health skilled nursing care for the monthly changing of the Foley catheter.  
 
We also decided that the Plan does not have to pre-approve frequent skilled nursing. 
 
Our physician reviewer found the enrollee is noted to be medically stable and does not require complex wound 
care, frequent catheterization, G-tube feeding, or administration of intravenous or complex medications. The 
enrollee does require significant assistance with mobility and daily activities, but his level of function and 
mobility has not significantly changed. The enrollee requires assistance for mobility and daily activities, but 
does not require skilled home services, including skilled nursing and therapy.  
 
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 at issue have not been met. Therefore, we decided that the Plan 
does not have to pre-approve frequent skilled nursing. 
 
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.