Appeal type: Home Health
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 7 additional physical therapy visits. We decided that the Plan does 
not have to pre-approve additional skilled nursing visits and more than 7 physical therapy visits.  
 
You asked the Plan to pre-approve additional skilled nursing visits and additional physical therapy visits. You 
say that you feel a nurse is important for the enrollee to get better from their wound. The Plan says that the 
records do not indicate that the enrollee meets the conditions for coverage. The Plan also says the enrollee's 
wound is improving and they are ambulatory within their home. 
 
We decided that the Plan has to pre-approve 7 additional physical therapy 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 7 additional physical therapy visits. Our 
reviewer says that 7 additional physical therapy visits are medically reasonable and necessary. Our physician 
reviewer found the enrollee's coccygeal pressure wound has improved, and the enrollees caregiver has been 
educated in terms of wound care and pressure relief. The enrollee can ambulate and perform transfers but still 
needs some degree of assistance. Our reviewer found that four additional visits of skilled nursing care were 
approved by the Plan. The enrollee has been slow to progress with regards to improving their strength and 
mobility. Our physician reviewer found that therefore, additional physical therapy visits would be beneficial in 
terms of improving function and mobility and transitioning to a home exercise program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 7 additional physical therapy visits have been met. Therefore, we decided that 
the Plan has to pre-approve 7 additional physical therapy visits.  
 
We also decided that the Plan does not have to pre-approve additional skilled nursing visits and more 
than 7 physical therapy 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 additional skilled nursing visits and 
more than 7 physical therapy visits. Our reviewer says that the additional visits of skilled nursing care are not 
medically necessary since four visits were approved by the Plan, and 7 sessions of physical therapy can be 
considered medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional skilled nursing visits and more than 7 physical therapy visits have not 
been met. Therefore, we decided that the Plan does not have to pre-approve additional skilled nursing visits and 
more than 7 physical therapy 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.