Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health skilled nursing care and home health aide 
services provided from October 3, 2022 through October 31, 2022.  
 
You asked the Plan to pay for home health skilled nursing care and home health aide services. You say that the 
services were medically necessary. The Plan denied your request. The Plan says the services are not medically 
necessary. There is no documentation of ongoing medical management requiring skilled nursing oversight such 
as: no administration of IV antibiotics, no new PEG tube or colostomy management, and no documentation of 
ongoing medical management changes. 
 
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. The rules say that HHA services may be covered if it is medically necessary for the 
enrollee to receive skilled nursing or therapy. 
 
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 pay for home health skilled nursing care and home 
health aide services. Our reviewer says that the services are not medically reasonable and necessary. Our 
physician reviewer found the enrollee has diagnoses of HTN, cardiomyopathy, poly-osteoarthritis, type 2 
diabetes, COPD, hypothyroidism, and dementia. Home health services including registered nurse, physical 
therapy and occupational therapy home health aide began on November 6, 2021. There has been no recent 
hospitalization. There has been no recent change in clinical status or treatment. Education on medical 
condition, medical management, and safety have been completed. The current request for care does not require 
the skills of a licensed nurse. Additionally, the care and treatment plan do not appear to for a limited period of 
time. The requested care is for convenience and does not meet criteria. The enrollee does not meet criteria for 
concurrent skilled nursing care, physical therapy, occupational therapy, or speech therapy. Therefore, the 
enrollee is not eligible for a home health aide. The review has determined that the records did not show that 
skilled nursing services were 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. The records did not show that skilled therapy services were 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 enrollees level of function and/or prevent 
deterioration. The home health aide services were not reasonable or necessary to the treatment of the enrollees 
illness or injury by the skilled professional staff. 
 
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 skilled nursing care and home health aide services have not been 
met. Therefore, we decided that the Plan does not have to pay for home health skilled nursing care and home 
health aide services provided from October 3, 2022 through October 31, 2022.