Appeal type: SNF
Decision: Favorable

We decided that the Plan has topre-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 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 admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are necessary. Our physician reviewer found the member has a relevant past medical history of advanced dementia with two recent hospitalizations with apparent treatment for acute renal failure. She had been receiving care at home with her family reporting increased lethargy and confusion over the previous week and increased evidence of pain. Her appetite had decreased and she has stopped ambulating. The member lives next to her daughter who is intermittently present throughout the day. She had previouslyrequired minimal assistance for activities of daily living and had been independent with ambulation and transfers. As of 03/03/2020 she required maximum assistance for bed mobility and transfers and maximum assistance when ambulating 10 feet with a front wheeled walker. She required maximum assistance for upper and lower body dressing and toileting. The member has advanced dementia with a decline in function over a 1-week period of time as described above. The member has pain which needs to be assessed andtreated. Her pain management is complicated by her cognitive impairment. The member requires oversight of her medical conditions and medication management. Due to her cognitive impairment she would not be expected to be able to adjust medications or self-monitor her medical conditions. She is at risk for secondary complications of immobility such as pressure ulcers and contractures. The member has not returned to her prior level of function. She had previously been able to ambulate and transfer independently and only required minimal assistance for activities of daily living and now requires maximum assistance for all activities.The member requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptiveequipment. The member requires both daily skilled therapy and nursing services. She is unable to perform essential activities of daily living such as bed mobility without assistance. She is unable to ambulate household distances without assistance. The member's condition would be expected to deteriorate with services provided on a less than daily basis. The member had previously been cared for at home. 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 admission to a skilled nursing facility (SNF) have beenmet.Therefore, we decided that the Plan has to pre-approveadmission to a skilled nursing facility (SNF).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.