Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules todetermine if the Plan was correct in denying the request to pre-approve admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member was admitted for acute care with new onset seizures with a CT scan of the head showing findings of a new large right subdural hematoma treated with a burr hole. He failed a swallowing study with findings of oropharyngeal dysphagia and underwent PEG tube placement. His relevant past medical history includes a prior subdural hematoma in 2015, expressive aphasia, dementia, and obstructive sleep apnea. He had previously been able to function independently including mowing his yard. The member lives with his spouse in a single level residencewith 2 steps to the entrance. As of 03/17/2020 he was able to eat his meals and no PEG tube feedings were being given. On 03/19/2020 he was able to perform bed mobility with standby assistance. He was able to transfer with standby assistance without a device and was ambulating 900 feet with contact-guard assistance and a front wheeled walker with 2 ambulation breaks. He had fair cadence with normal stride length with a tendency to lift up the walker when turning without demonstrated loss of balance. The member is status-post acute care admission as described above. There are no skilled nursing needs. The member is not receiving IV medications or fluids. Routine monitoring of his chronic medical conditions is being done such as assessment of pain, routine administration of oral medications, support of chronic physical debilities, and assessment of his skin condition. There are no unaddressed medical conditions or conditions that require complex monitoring or medication adjustments. The member has not returned to his prior level of function. The member requires physical therapy for progression of his mobility at a community level and to establish a maintenance home exercise program. An occupational therapy evaluation is indicated to assess the need for any adaptive equipment. There are skilled needs, but they do not need to be provided on a daily basis. The member is ambulating greater than household distances and performing essential activities of daily living without hands on assistance. The member is receiving care that can be provided by his non-skilled caregivers with periodic skilled oversight and modification of the care plan if needed. The member's condition would not be expected to deteriorate with services provided on a less than daily basis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a skilled nursing facility (SNF) have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).