Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Kidney Disease

Treatment: Skilled Nursing Facility (SNF) Alternate Level of Care

The insurer denied coverage for Skilled Nursing Facility (SNF) Alternate Level of Care

The denial is upheld

In an undated correspondence, the resident has a long list of diagnosis that includes chronic kidney disease, stage 3; type 2 diabetes without complications, essential primary hypertension, weakness, hyperlipidemia, immunodeficiency, disorder with related psychological factors, benign prostatic hyperplasia with lower urinary tract symptoms. The resident had a surgical procedure which required skilled nursing intervention for wound dressing and monitoring for signs and symptoms of infection, which was provided. The resident developed an increase in confusion and dizziness. In addition, nursing education was provided and return demonstration to educate the resident on how to perform self-injection. Discharge planning was unsuccessful due to the patient's increased needs for more home health aide (HHA) support. Further, the patient has no family support available and their apartment was not ready for discharge due to them being in the arrears for overdue rent. 

According to the occupational therapy (OT) progress notes, the resident is moderately dependent with a total assessment score of 66 and the physical therapy (PT) assessment total score was 8/11, interpreted as moderate risk for falls.

The request was previously denied as not medically necessary. It was determined that the resident had no further skilled need and the skilled episode of care ended. In addition, New York State Law requires biweekly submission of current Patient Review Instrument as a condition of prior authorization for the 1st thirty days. Alternate Level of Care is considered medically necessary only for individuals who have an established discharge date for whom a discharge plan cannot be executed because of one or more variables that must be resolved before the discharge is completed. This level of care can only be considered prospectively. In accordance with New York State (NYS) Law (18 New York Codes, Rules and Regulation [NYCRR] 505.20 (b)(2)), failure by the facility to notify Healthfirst prior to or within 24 hours of the patient's assignment to alternate care status shall result in denial of payment for care rendered on or after that date. In addition, NYS Law requires biweekly submission of current PRI (Patient Review Instrument) as a condition of prior authorization for the 1st thirty days. In this instance the resident or their representative did not submit an updated Patient Review Instrument submitted prior to the end of the patient's skilled nursing or rehab services and did not have a mutually approved safe discharge plan with a valid justification for why this plan had not been executed.

Based on the review of the medical records submitted, current PRI (Patient Review Instrument) was not submitted prior to the end of the skilled nursing services and no mutually approved safe discharge plan with a valid justification for why the plan has not been executed was submitted.  


The medical information received for the resident did not meet the criteria for the extended stay of the MCG. The resident is alert and oriented, OT and PT assessment showed that they are a moderate risk for falls and moderately dependent. Although the patient complained of pain after the arteriovenous (AV) fistula creation to the left upper extremity, the pain was managed by oral (PO) medications. Further, the patient had fever post dialysis and it was managed after taking Tylenol. In addition, no progress notes were provided for multiple dates of service.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Skilled Nursing Facility (SNF) Alternate Level of Care is not substantiated.