Why MA Plans Denies Home Health Services
Patient is not homebound
Skilled need not documented
Services exceed reasonable frequency
Know Medicare Advantage's Criteria
Medicare Advantage plans must cover all services covered by Original Medicare (CMS NCDs and LCDs) but may require prior auth. Plans use various criteria including InterQual, MCG, and proprietary guidelines.
Key policies to know:
- Must cover all services covered by Original Medicare
- Can require prior authorization not required by Original Medicare
- CMS NCDs and LCDs serve as coverage floor
- Organization determinations must be issued within 14 days (72 hours for expedited)
Building Your Medical Necessity Argument
Document homebound status with specific functional limitations
Define the skilled need (wound care, medication management, PT/OT)
Note why outpatient services are not feasible
Reference recent hospitalization or change in condition
P2P Call Tips for MA Plans
Cite the relevant CMS NCD or LCD -- MA plans cannot deny what Medicare covers
If the service has a CMS NCD, that trumps the MA plan's internal criteria
Reference CMS regulations on MA coverage obligations
Request expedited determination if clinical urgency exists
Guidelines to Reference
- CMS Home Health Coverage Requirements
- Medicare Benefit Policy Manual Ch. 7
Relevant CPT Codes
Specialty: Internal Medicine / Family Medicine
Want the full strategy?
The P2P Playbook covers payer-specific approaches for Home Health Services denied by MA Plans -- plus 15 denial objections with word-for-word responses, what reviewers are actually thinking, and the 60-second prep framework. Written by a medical director who reviewed cases for major payers.
Get The P2P Playbook -- $39Get a personalized P2P script in 60 seconds
Enter your specific case details and our AI generates a structured prep script tailored to MA Plans's criteria.