Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say to qualify for home health services, the patient must be: 
 
1. Confined to the home;  
2. Under the care of a physician or allowed practitioner;  
3. Receiving services under a plan of care established and reviewed by a physician;  
4. Be in need of (a) skilled nursing care on an intermittent basis, (b) physical therapy, (c) speech therapy or (d) 
continuing occupational therapy.  
You can find this rule at 42 CFR Section 409.42. 
 
The rules say that eligibility for the home health benefit will be determined based on the certifying physician or 
allowed practitioners records. If the enrollee was directly admitted to home health from an acute or post-acute 
care facility, the facility records may be used instead. The medical records for the enrollee must contain 
information that justifies the referral for home health services. 
  
The certifying physician or allowed practitioner must document that there was a face-to-face encounter with the 
enrollee within the required timeframe. The records must contain the actual clinical note for the face-to-face 
encounter visit. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Medicare Benefit Policy Manual, Publication 100-02, Chapter 7, Section 30.5.1, 30.5.1.1, and 
30.5.1.2. 
 
The rules say PT Evaluation and PT Re-evaluation 
 
Evaluation is a comprehensive service that requires professional skills to make clinical judgments about 
conditions for which services are indicated based on objective measurements and subjective evaluations of 
patient performance and functional abilities. Evaluation is warranted at the start of therapy or when the 
beneficiarys condition changes, or treatment needs change so as to potentially warrant a new plan of care or a 
change to an existing plan of care. The time spent in evaluation does not count as treatment time. 
 
1. The initial examination has the following components:  
a. The patient history to include prior level of function, 
b. Relevant systems review, 
c. Tests and measures, 
d. Current functional status (abilities and deficits), and 
e. Evaluation of patient's, physician's and as appropriate the caregiver's goals 
 
2. Factors that influence the complexity of the examination and evaluation process include the clinical findings, 
extent and duration of loss of function, prior functional level, social/environmental considerations, educational 
level, the patient's overall physical and cognitive health status, social/cultural supports, psychosocial factors 
and use of adaptive equipment. Thus, the evaluation reflects the chronicity or severity of the current problem, 
the possibility of multi-site or multi-system involvement, the presence of preexisting systemic conditions or 
diseases, and the stability of the condition. Physical therapists also consider the level of the current 
impairments and the probability of prolonged impairment, functional limitation, the living environment, prior 
level of function, the social/cultural supports, psychosocial factors, and use of adaptive equipment. 
 
3. Initial evaluations or re-evaluations may be determined reasonable and necessary even when the evaluation 
determines that skilled rehabilitation is not required if the patient's condition showed a need for an evaluation, 
or even if the goals established by the plan of treatment are not realized. 
 
4. Re-evaluation is considered reasonable and necessary when the beneficiarys condition changes, or treatment 
needs change so as to potentially warrant a new plan of care or a change to an existing plan of care. Some 
regulations and state practice acts require reevaluation at specific intervals. 
 
5. Re-evaluations are appropriate periodically to assess progress toward goals established in the plan of 
treatment, or to identify and establish interventions for newly developed impairments at least once every 30 
days, for each therapy discipline.  
 
Maintenance Programs 
 
A maintenance program is a program designed to help a beneficiary maintain an existing level of function or 
minimize a loss of function. Coverage of skilled rehabilitation services is contingent upon beneficiarys need 
for skilled care whether the goals of therapy include maintenance or improvement. You can find this 
information in Medicare's Local Coverage Determination (LCD): Home Health Physical Therapy (L34564). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.