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 enrollee meets criteria for the requested admission to a SNF. Our physician reviewer found the member was seen in an Emergency Room on 02/17/2020 with left-sided pain after being discharged 3 days before after undergoing a partial nephrectomy. She was found to have an intra-abdominal abscess and was admitted the next day. The member previously lived in a house with her son and daughter-in-law and had been independent with basic activities of daily living including ambulating without an assistive device. She underwent CT-guided drainage and required an exploratory laparoscopy with small bowel resection on 02/19/2020. Her hospital course was complicated by pneumonia and delirium which have resolved. She is on a regular diet. As of 03/04/2020 she required minimal assistance for bed mobility and standby assistance when transferring. She required contact-guard assistance when ambulating 40 feet x 2 with a slow velocity. She was tremulous when standing. She had increased fatigue. She continued to demonstrate a limited upright activity tolerance and generalized weakness after her prolonged hospital stay and sepsis. She required frequent long rest breaks for pacing. In occupational therapy on 03/06/2020 she was able to perform bed mobility at a modified independent level. She was walking household distances in her room with contact-guard assistance. She required assistance when transferring to a toilet. She almost fell when performing a toilet transfer. She had a fair activity tolerance. There were no signs or symptoms of distress during the treatment. A medical progress note dated 03/06/2020 indicates that she was progressing. She denied abdominal pain. She was tolerating her diet without nausea or vomiting. She was having loose stools. Physical examination findings included a normal body mass index. Her abdomen was soft and nondistended without tenderness to palpation. Her midline incision was clean, dry, and intact with mild erythema where the staples had been. There was a nonfocal neurologic examination. The member is status-post acute care admission as described above with complicated course after undergoing a partial nephrectomy. The member continues to receive wound care.She has pain which needs to be assessed and treated. The member requires oversight of her medical conditions and medication management. She is at an increased risk for further complications including infection and recurrent bowel obstruction. The member has not returned to her prior level of function. The member requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. The member requires both daily skilled therapy and nursing services.She is unable to ambulate household distances continuously due to fatigue and decreased endurance. She requires intermittent assistance when performing transfers. The member's condition would be expected to deteriorate with services provided on a less than daily basis. The member had previously been able to function independently. There is a reasonable expectation of a reduction in burden of care with a goal of a successful return to the community 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 caseagain, we will send you a letter.