Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says that 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 to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the requested admission to a SNF meets criteria. Our physician reviewer found the enrollee was admitted for acute care on 01/09/2020 with chest pain for the past 6 days. She had recently been discharged after undergoing a substantial work-up and treatment of an abdominal wall abscess in October 2019. She is also overweight with a body mass index of 38. She was treated for bacteremia and acute kidney injury. Her discharge planning needs were addressed on 01/13/2020. She had previously required maximum assistance x2 for transfers. She reported not wanting to return for SNF level care. Long-term care was being considered. On 01/16/2020 the enrollee had not previously worked with physical therapy as her ostomy bag had been leaking and she had been unable to get out of bed. She was now willing to work with therapy and her ostomy bag was now working well. She was evaluated for physical therapy on 01/20/2019. She had previouslybeen transferred with a Hoyer lift and had been at a dependent level of function for all activities other than for grooming. When evaluated she had pain rated at 7.5/10. She was alert and cooperative. She had upper extremities range of motion within functional limits with strength graded at 4/5. She had lower extremity strength ranging from 2-/5 to 3+/5. She required maximum assistance for bed mobility when transitioning from supine to seated and was dependent when transitioning back to supine. She required up to moderate assistance for maintaining her seated balance. The therapy report references an apparent good potential for improving her strength, endurance, bed mobility, and transfers. The enrollee is status-post admission and treatment for bacteremia and acute kidney injury as described above. The member continues to receive ostomy care. She has pain which needs to be assessed and treated. The enrollee requires oversight of her medical conditions and medication management. She is at risk for secondary complications of immobility such as pressure ulcers and contractures. The enrollee requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. The enrollee requires both daily skilled therapy and nursing services. She is unable to perform essential activities of daily living such as bed mobility without assistance. The enrollee's condition would be expected to deteriorate with services provided on a less than daily basis. The enrollee's ostomy bag appears to be functioning well and she appears motivated to participate in rehabilitation therapy efforts. She has adequate upper extremity strength with normal range of motion and should be able to perform bed mobility and transfer without hands-on assistance. There is a reasonable expectation of a reduction in burden of care through the SNF level care being requested.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted.Therefore, we decided that the Plan has to pre-approveskilled nursing facility (SNF) care.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.