Health Law Daily Patient fails to get lifetime preapproval of home health services
Tuesday, November 19, 2019

Patient fails to get lifetime preapproval of home health services

By Patricia K. Ruiz, J.D.

The court found that a patient’s request for lifetime home health services was not medically necessary.

The Eastern District of California upheld decisions by the administrative law judge (ALJ) and the Medicare Appeals Counsel denying a patient lifetime preapproval of home health services. The court found that the patient did not have a plan of care from his physician ordering home health service and did not find a basis to find that home health services were medically necessary (Storman v. HHS, November 13, 2019, Claire, A.).

Request for home health services. In November 2017, a patient with multiple health conditions told his primary care physician he was interested in permanent home health services. The physician told the patient that such services are usually for short-term rehabilitation after an acute decline in function but told the patient he would ask the social work team if any more could be done for him. The physiciant told his patient in December 2017 that he should receive home care every week or two for an indefinite length of time because of his multiple conditions. The physician noted the patient was not able to articulate his skilled nursing need other than describing his mental and emotional state as unstable. The physician declined to prescribe home health care services because of the lack of need but recommended resources that may be available, including transportation through his health plan. The patient’s other physicians declined to or did not order home health services for the patient.

Denial. The patient requested approval of home health services by his insurer, Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan North (Kaiser). Kaiser denied the request for home health services, concluding the patient was not qualified to receive them. The patient appealed his denial to his plan, which agreed with the denial and sent the case to an independent reviewer. The reviewer affirmed the denial, finding that the patient did not meet the requirements for home health services because the services were not medically necessary, indefinite home health services were not reasonable and necessary for treatment, and the patient was not home bound.

Appeals. The patient requested hearing before an ALJ. The ALJ issued an unfavorable decision, holding the plan was not required to approve the patient’s request for home health care and finding no evidence that the patient was homebound. To qualify for Medicare coverage of home health services, a plan of care is needed for home health services. The patient’s record did not reflect a plan of care ordering home health services. The patient appealed to the Medicare Appeals Counsel, which held that the patient did not qualify for lifetime home health services. The patient filed suit in September 2018.

The court found that the decisions of the ALJ and the Medicare Appeals Counsel were supported by substantial evidence. To qualify for home health services, a beneficiary must be (1) confined to the home; (2) under the care of a physician who establishes a pan of care; (3) in need of skilled services; (4) under a qualifying plan of care that meets regulatory requirements; and (5) receiving services from a participating home health agency. The court found that the Secretary was justified in concluding that the patient does not meet these requirements. The court noted that, notwithstanding the lack of a plan of care for the patient requiring home health services, lifetime preapproval of home health services is not available.

The case is No. 2:18-cv-02654.

Attorneys: Michael D. Storman, pro se. Chi Soo Kim, U.S. Attorney's Office, for U.S. Office of the Secretary of Health & Human Services.

Companies: U.S. Office of the Secretary of Health & Human Services

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