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 state that medical necessity determinations should be focused only on the NEED FOR SKILLED 
SERVICES to provide treatment to the patient. The potential for improvement is not a determining factor. 
Specifically, are skilled services required to treat the patient's illness or injury, improve the patient's condition, 
maintain the patient's condition, or prevent deterioration of the patient's condition? 
 
The rules say that the physician or allowed practitioner's orders for services in the plan of care must specify the 
medical treatments to be furnished as well as the type of home health discipline that will finish the ordered 
services and at what frequency the services will be furnished. Orders for services to be provided as needed or 
PRN must be accompanied by a description of the beneficiary's medical signs and symptoms that would 
occasion the visit and a specific limit on the number of those visits to be made under the order before an 
additional physician or allowed practitioner order would have to be obtained. Orders for care may indicate a 
specific range in frequency of visits to ensure that the most appropriate level of services is furnished. If a range 
of visits is ordered, the upper limit of the range is considered the specific frequency. This can be found in 42 
CFR 409.43 
 
The rules say that to qualify for coverage of medically reasonable and necessary home health services, the 
patient must be confined to the home and need one of the following types of services:  
 
1.SKILLED NURSING CARE THAT IS:  a. Reasonable and necessary as defined in Section 40.1;  
b. Needed on an intermittent based as defined in Section 40.1.3; and  
c. Not solely needed for venipuncture for the purposes of obtaining blood samples in Section 40.1.2.13;    
 
2. PHYSICAL THERAPY AS DEFINED IN SECTION 40.2.2;   
 
3. SPEECH-LANGUAGE PATHOLOGY SERVICES AS DEFINED IN SECTION 40.2.3;   
 
4. CONTINUING NEED FOR OCCUPATIONAL THERAPY AS DEFINED IN SECTION 40.2.4  
 
The patient has a continued need for occupational therapy when:  
 
1. The services which the patient requires meet the definition of occupational therapy services of Section 
40.2.4, and  
2. Patient eligibility for home health services has been established by virtue of a prior need for skilled nursing 
care (other than solely venipuncture for the purposes of obtaining a blood sample), speech-language pathology 
services, or physical therapy in the current or prior certification period.  
 
In addition, for home health aide services to be covered:  
 The patient must meet the qualifying criteria as specified in Section 30; 
 The services provided by the home health aide must be part-time or intermittent as discussed in Section 50.7; 
 The services must meet the definition of home health aide services of this section; and 
 The services must be reasonable and necessary to the treatment of the patient's illness or injury. 
 
The full text of the above rule (Medicare Benefit Policy Manual, Chapter 7), including many helpful examples 
of covered services, can be found on the Case Documents tab under RegCitations: 
Confined to Home: Section 30.1.1 Page 23 
Skilled Nursing Care: Section 40.1 Pages 41-64 
Physical Therapy: Section 40.2.2 Pages 64-77 
Speech-Language Pathology Services: Section 40.2.3 Pages 73-74 
Occupational Therapy: Section 40.2.4, Pages 74-75 
Home Health Aide services: Section 50.2, Pages 78-80 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.