Detailed Explanation of Non-coverage (DENC)

Riverbend Home Health 220 Hatcher Lane, Columbia, TN 38401 Toll-free phone: 1-866-555-0129 ## Notice: Why Your Home Health Care Is Ending Date: March 12, 2025 Patient name: Walter Pruitt This letter tells you why your provider and/or health plan has decided that Medicare will stop paying for your current home health services. This letter is not the answer to an appeal. If you appeal, your Quality Improvement Organization (QIO) will make that decision. ## Why Medicare will stop paying for your care We looked at your case. We decided that Medicare should stop paying for your home health care. - **What we looked at:** Your nurse's visit notes from March 3 and March 10, 2025. These notes show that your surgery wound has closed. You no longer need wound care every day. - **Why this means your care is no longer covered:** Medicare pays for home health care only when you need a nurse or therapist on a part-time, as-needed basis. You or a family member or caregiver can now care for your wound. Because of this, you no longer need a skilled nurse. The Medicare rule we used is Medicare Benefit Policy Manual, Chapter 7, Section 40.1. - **Health plan rules:** These do not apply to you. You have Original Medicare. If you want a copy of the rules we used to make this decision, or a copy of the papers we sent to the QIO, call us at 1-866-555-0129. You have the right to get this information in a different format, such as large print, Braille, or audio. You also have the right to file a complaint if you think you have been treated unfairly because of who you are. To learn more, visit Medicare.gov/about-us/accessibility-nondiscrimination-notice or call 1-800-MEDICARE (1-800-633-4227). If you use a TTY, call 1-877-486-2048.

**Riverbend Home Health** 220 Hatcher Lane, Columbia, TN 38401 Toll-free: 1-866-555-0129 ## Why Medicare Will Stop Paying for Your Care **Date:** March 12, 2025 **Patient:** Walter Pruitt Dear Mr. Pruitt, This letter tells you why Medicare will stop paying for your care. It is not the answer to your appeal. If you appeal, a group called the Quality Improvement Organization (QIO) will make that decision. ## Why Medicare will stop paying We looked at your case. We decided that Medicare should stop paying for your home health care. **What we based our decision on:** Your nurse wrote notes on March 3 and March 10, 2025. The notes show that your surgery wound has closed. You do not need wound care every day anymore. **Why this means Medicare will stop paying:** Medicare pays for home health care only when you need a skilled nurse or therapist to visit from time to time. You or a caregiver can now take care of your wound. So you no longer need a skilled nurse. We used this Medicare rule: Medicare Benefit Policy Manual, Chapter 7, Section 40.1. **Plan rules:** This does not apply to you. You have Original Medicare. ## How to get more information You can ask for a copy of the rules we used. You can also ask for a copy of the papers we sent to the QIO. To ask, call us at 1-866-555-0129. ## Your rights - You can get this letter in other formats, such as large print, Braille, or audio. - You can file a complaint if you think you were treated unfairly because of who you are. To learn more, go to Medicare.gov/about-us/accessibility-nondiscrimination-notice. You can also call 1-800-MEDICARE (1-800-633-4227). If you use a TTY, call 1-877-486-2048.

Riverbend Home Health 220 Hatcher Lane, Columbia, TN 38401 Free phone number: 1-866-555-0129 ## Why Medicare Will Stop Paying for Your Home Health Care Date: March 12, 2025 Patient name: Walter Pruitt This letter tells you why we decided that Medicare should stop paying for your home health care. This letter is **not** the answer to your appeal. (An appeal is when you ask someone to look at a decision again.) The answer to your appeal will come from a different group. This group is called the Quality Improvement Organization, or QIO. ## Why Medicare will stop paying We looked at your care. We decided that Medicare should stop paying for your home health care. **What we looked at:** Your nurse visited you on March 3 and March 10, 2025. The nurse's notes say that the wound from your surgery has closed. You do not need care for your wound every day anymore. **Why this matters:** Medicare only pays for home health care when you need a trained nurse or therapist to help you from time to time. Now, you or someone who helps you can take care of your wound. You do not need a trained nurse for this anymore. So Medicare will stop paying. The rule we used is in the *Medicare Benefit Policy Manual, Chapter 7, Section 40.1*. **Health plan rules:** This part does not apply to you. You have Original Medicare, not a private health plan. ## How to get more information Do you want a copy of the rules we used? Do you want a copy of the papers we sent to the QIO? Call us at **1-866-555-0129**. ## Your rights You can ask for this letter in a form that is easier for you to use, such as: - Large print - Braille - Audio (a recording you can listen to) If you think you were treated unfairly because of who you are, you can make a complaint. To learn more: - Go to **Medicare.gov/about-us/accessibility-nondiscrimination-notice** - Or call **1-800-MEDICARE (1-800-633-4227)** - If you use a TTY phone (for people who are deaf or hard of hearing), call **1-877-486-2048**

**Riverbend Home Health** 220 Hatcher Lane, Columbia, TN 38401 Phone (free): 1-866-555-0129 **Why Your Medicare Coverage Is Ending** Date: March 12, 2025 Patient: Walter Pruitt Dear Mr. Pruitt, This letter tells you why Medicare will stop paying for your home health care. This letter is not the answer to your appeal. If you appeal, a group called the Quality Improvement Organization (QIO) will make that choice. **Why Medicare will stop paying** We looked at your case. We decided that Medicare should stop paying for your home health care. **What we based this on:** Your nurse wrote notes on March 3 and March 10, 2025. The notes say your wound from surgery has closed. You do not need wound care every day anymore. **Why this matters:** Medicare pays for home health care only when you need a nurse or therapist to visit now and then. You or a helper at home can now take care of your wound. So you do not need a nurse to do it. The rule we used is in the Medicare Benefit Policy Manual, Chapter 7, Section 40.1. **Plan rules:** This does not apply to you. You have Original Medicare. **Want a copy of the rules?** You can ask for a copy of the rules we used. You can also ask for a copy of the papers we sent to the QIO. Just call us at 1-866-555-0129. **Your rights** - You can get this letter in a way that is easy for you to use. This can be large print, Braille, or audio. - You can make a complaint if you think someone treated you unfairly. To learn more, go to Medicare.gov/about-us/accessibility-nondiscrimination-notice. Or call 1-800-MEDICARE (1-800-633-4227). If you use a TTY, call 1-877-486-2048.

**Riverbend Home Health** 220 Hatcher Lane, Columbia, TN 38401 Toll-free: 1-866-555-0129 **Why Medicare Will Stop Paying for Your Care** Date: March 12, 2025 Patient: Walter Pruitt Dear Mr. Pruitt, This letter explains why Medicare will stop paying for your home health care. This letter is not the answer to your appeal. If you appeal, a group called the Quality Improvement Organization (QIO) will make that decision. **Why Medicare will stop paying** We looked at your case. We decided that Medicare should stop paying for your home health care. **What we based this on:** Your nurse visited you on March 3 and March 10, 2025. Her notes show that the wound from your surgery has closed. You no longer need wound care every day. **Why this means coverage ends:** Medicare pays for home health care only if you need skilled nursing or therapy from time to time. You or a caregiver can now take care of your wound. That means you no longer need a skilled nurse. The rule we used is in the Medicare Benefit Policy Manual, Chapter 7, Section 40.1. **Health plan rules:** These do not apply to you. You have Original Medicare. **How to get more information** You can ask for a copy of the rules we used. You can also ask for a copy of the papers we sent to the QIO. To do either, call us at 1-866-555-0129. **Your rights** - You can ask for this information in a format that works for you. Choices include large print, Braille, or audio. - You can file a complaint if you think you were treated unfairly because of who you are. To learn more, visit Medicare.gov/about-us/accessibility-nondiscrimination-notice. You can also call 1-800-MEDICARE (1-800-633-4227). If you use a TTY, call 1-877-486-2048.

**Riverbend Home Health** 220 Hatcher Lane, Columbia, TN 38401 Toll-free phone: 1-866-555-0129 **Why Your Medicare Coverage Is Ending** Date: March 12, 2025 Patient: Walter Pruitt Dear Mr. Pruitt, This letter tells you why your home health care provider decided that Medicare should stop paying for your services. Your provider may be working with your health plan on this. This letter is not the answer to your appeal. If you appeal, the answer will come from your Quality Improvement Organization. This group is called the QIO. **Why Medicare will no longer pay for your services** We looked at your case. We decided that Medicare should stop paying for your home health services. **The facts we used:** - Your nurse wrote notes after visits on March 3 and March 10, 2025. - The notes show that your surgery wound has closed. - You no longer need wound care every day. **Why your services are ending, and the rule we used:** - Medicare pays for home health care only while you need skilled nursing or therapy from time to time (not every day). - You or a caregiver can now take care of your wound. - This means you no longer need a skilled nurse. - The rule we used is in the Medicare Benefit Policy Manual, Chapter 7, Section 40.1. **Health plan rule:** - We did not use a health plan rule. This does not apply to you because you have Original Medicare. **How to get copies of papers** You can ask us for: - A copy of the rules or guidelines we used to make this decision. - A copy of the papers we sent to the QIO. To ask, call us at 1-866-555-0129. **Your rights** - You have the right to get this information in a form that is easy for you to use. For example, you can ask for large print, Braille, or audio. - You have the right to file a complaint if you think you were treated unfairly because of who you are. To learn more, you can: - Go to Medicare.gov/about-us/accessibility-nondiscrimination-notice - Call 1-800-MEDICARE (1-800-633-4227) - If you use a TTY, call 1-877-486-2048

**Riverbend Home Health** 220 Hatcher Lane, Columbia, TN 38401 Toll-free: 1-866-555-0129 **Date:** March 12, 2025 **Patient:** Walter Pruitt # Why Medicare Will Stop Paying for Your Home Health Care ## What this letter is This letter explains why we decided that Medicare coverage of your home health services should end. This letter is **not** the decision on your appeal. The decision on your appeal will come from your Quality Improvement Organization (QIO). ## What we decided We looked at your case. We decided that Medicare coverage of your home health services should end. ## The facts we used - Your nurse wrote visit notes on March 3 and March 10, 2025. - The notes show that your surgical wound has closed. - You no longer need daily wound care. ## Why your services are no longer covered - Medicare covers home health care only while you need skilled nursing or therapy on an intermittent basis. (Intermittent means from time to time, not all the time.) - You or a caregiver can now do your wound care. - So you no longer need skilled nursing. ## The rule we used Medicare Benefit Policy Manual, Chapter 7, Section 40.1. ## Plan policy We did not use a specific plan policy. This does not apply to you because you have Original Medicare. ## How to get copies You can ask for a copy of the rules or guidelines we used to make this decision. You can also ask for a copy of the documents sent to the QIO. To ask, call us at **1-866-555-0129**. ## Your rights - You have the right to get your information in a format you can use. This includes large print, Braille, or audio. - You have the right to file a complaint if you feel you were treated unfairly because of who you are (discrimination). ## Where to get more information - Visit: Medicare.gov/about-us/accessibility-nondiscrimination-notice - Call Medicare: **1-800-MEDICARE (1-800-633-4227)** - TTY users: call **1-877-486-2048** ## How to reach us **Riverbend Home Health** 220 Hatcher Lane, Columbia, TN 38401 Toll-free: 1-866-555-0129