Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the continuation of skilled nursing facility (SNF) care. You say that the
requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the
requested continuation of SNF care 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 to
determine if the Plan was correct in denying the request to pre-approve the continuation of skilled nursing
facility (SNF) care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer
found the enrollee was admitted to acute care with a non-healing wound at the right below knee amputation
(BKA) site. She underwent incision and drainage (I&D) with wound vac placement and was admitted to SNF
on 12/11/19. The enrollee was receiving wound care to the right below knee amputation site with a wound vac,
left heel non pressure wound, and left foot, third toe amputee site. The enrollee states that they need more
therapy and have a wound vac on legs and the left foot is not good. There is also a sore on the heel since
admission. Per records the wound vac was changed every Wednesday, Saturday, and as needed. The left heel
wound skin prep was done every shift (3 time's per day). The left heel wound boot heel cut out ordered. The
left foot amputee site third toe was changed every 8 hours and as needed. On 1/9/20 the enrollee can propel the
wheelchair over 500 feet but prefers to be pushed and does not initiate activity. On 1/17/20 the enrollee needed
stand-by assist with squat pivot transfer, minimal assist for part management, and stand-by assist with
wheelchair mat table transfer. On 1/20/20 the enrollee needed contact guard assist for transfers, stand-by assist
for sit to stand, and contact guard assist for bed transfers. On 1/21/20 the enrollee needed minimal assist with
sit to stand with 2 wheeled walker. Sitting balance was good. Standing balance was poor. In occupational
therapy the enrollee could perform therapeutic resistance exercises and on 1/20/20 was minimal assist with
verbal and visual cues for exercise.
Based on the documentation provided, this enrollee does not require skilled nursing services with the
specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide
medically necessary and reasonable treatment in a SNF after 1/19/20. The enrollee does not have a
tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need after 1/19/20.
The enrollee's wound vac does not need to be changed on a daily basis. This enrollee's functional level does not
require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist
required to safely and effectively provide medically necessary and reasonable treatment in a SNF after 1/19/20.
The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these
services) on a daily basis. As a practical matter this enrollee does not require the necessary services on an
inpatient basis, in a skilled nursing facility setting after 1/19/20.
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 continuation of skilled nursing facility (SNF) care have not been met.
Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility
(SNF) care.