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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 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 (e.g., for a new diagnosis or when a 
condition is treated in a new setting). These evaluative judgments are essential to development of the plan of 
care (POC), including goals and the selection of interventions. The time spent in evaluation does not count as 
treatment time. 
 
1. The initial examination must have components as described in CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, 40.2.1 General Principles Governing Reasonable and Necessary 
Physical Therapy. 
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. Occupational 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 periodically indicated during an episode of care when the professional assessment indicates 
a significant improvement or decline in the patients condition or functional status that was not anticipated in 
the POC. Some regulations and state practice acts require re-evaluation at specific intervals. A re-evaluation is 
focused on evaluation of progress toward current goals and making a professional judgment about continued 
care, modifying goals and/or treatment or terminating services. 
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. A re-evaluation may be appropriate prior to a planned discharge for the 
purposes of determining whether goals have been met or for the use of the physician or the treatment setting at 
which treatment will be continued. You can find this information in Medicare's Local Coverage Determination 
(LCD): Home Health Occupational Therapy (L34560). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.