Appeal type: SNF
Decision: Partially Favorable

We decided that the Plan has to pay for the skilled nursing services provided from May 18, 2019 to June 5,
2019. We decided that the Plan does not have to pay for the skilled nursing services provided from June 6,
2019 to June 16, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan says that the enrollee did not require any
additional skilled services that could not have been provided in an alternate setting other than a SNF.
We decided that the Plan has to pay for the skilled nursing services provided from May 18, 2019 to June 5,
2019.
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 to
determine if the Plan was correct in denying the request to pay for the skilled nursing services provided from
May 18, 2019 to June 5, 2019. Our reviewer says that the enrollee did meet the Medicare criteria for SNF care
for May 18, 2019 to June 5, 2019. Our physician reviewer found the enrollee did have daily skilled nursing
needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee
did have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled
professional therapist. The enrollee did require daily skilled nursing and/or skilled therapy on an inpatient basis
in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the skilled nursing services provided from May 18, 2019 to June 5, 2019 have
been met. Therefore, we decided that the Plan has to pay for the skilled nursing services provided from May
18, 2019 to June 5, 2019.
We also decided that the Plan does not have to pay for the skilled nursing services provided from June 6,
2019 to June 16, 2019.
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 to
determine if the Plan was correct in denying the request to pay for the skilled nursing services provided from
June 6, 2019 to June 16, 2019. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF
care for June 6, 2019 to June 16, 2019. Our physician reviewer found the enrollee did not have daily skilled
nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The
enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment
of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on
an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the skilled nursing services provided from June 6, 2019 to June 16, 2019 have
not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided
from June 6, 2019 to June 16, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.