Appeal type: Home Health
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve home health physical therapy. We decided that the Plan does not 
have to pre-approve home health aide, home health speech therapy, and home health skilled nursing.  
 
You asked the Plan to pre-approve home health aide (G0156 x9), home health physical therapy (G0151 x9), 
home health speech therapy (G0153 x5), and home health skilled nursing (G0299 x5).. You say that the 
services are medically necessary. The Plan says that the requested services are not medically necessary. 
 
We decided that the Plan has to pre-approve home health physical therapy.  
 
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 home health physical therapy. Our 
reviewer says that the service is medically necessary. Our physician reviewer found the clinical documentation 
shows that the enrollee is home bound and has functional impairments and discusses need for other durable 
medical equipment (wheelchair), physical assistance with mobility thus the records show that skilled physical 
therapy services 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 enrollee'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 home health physical therapy have been met. Therefore, we decided that the 
Plan has to pre-approve home health physical therapy.  
 
We also decided that the Plan does not have to pre-approve home health aide, home health speech 
therapy, and home health skilled nursing. 
 
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 pre-approve home health aide, home health speech 
therapy, and home health skilled nursing. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found that the clinical documentation does not list any recent medication changes, clinical 
status changes or concerns (only foot care-without any specific reason) thus the records do not show that 
skilled nursing services 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 enrollee's condition 
and/or prevent deterioration. Additionally, no care plan is provided in which the skilled services of a home 
health aide would be required. Clinical documentation states that the enrollee has dementia but does not specify 
any specific speech therapy goal (dysphagia, cognition) with only mention of non-compliance thus the records 
do not show that skilled speech therapy services 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 enrollee'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 home health aide, home health speech therapy, and home health skilled nursing 
have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide, home 
health speech therapy, and home health 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.