Appeal type: SNF
Decision: Partially Favorable

We decided that the Plan has to make payment for the SNF services provided from May 18, 2019 to May 20, 2019. We decided that the Plan does not have to make payment for the SNF care provided from May 10, 2019 to May 17, 2019 and from May 21, 2019 to June 8, 2019..
You asked the Plan to make payment for the SNF services provided from May 18, 2019 to May 20, 2019. You say that it is felt that Medicare criteria were met and that CT Medicaid should be reimbursed for payments made for this stay. The Plan says that the enrollee's care was custodial in nature for this set of dates and cannot be covered by Medicare.
We decided that the Plan has to make payment for the SNF services provided from May 18, 2019 to May 20, 2019.
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 make payment for the SNF services provided from May 18, 2019 to May 20, 2019. Our reviewer says that the documentation shows that the enrollee that daily skilled nursing care was required from May 18, 2019 to May 20, 2019; however, the remainder of the dates at issue were custodial in nature. Our physician reviewer found The enrollee presented to the hospital on 5/6/19 with left-sided chest pain and altered mental status. She was hypotensive, had an abnormal urinalysis, and leukocytosis. She was diagnosed with a UTI, severe sepsis, chest pain, rapid atrial fibrillation, acute on chronic anemia, acute kidney injury, and altered mental status. There was evidence of GI bleeding. The Internal Medicine Progress Note dated 5/8/19 documents that the enrollee was on IV antibiotics, and was slowly improving. She was transferred to the SNF on 5/10. On 5/18/19, the enrollee was not feeling well. She was found to be hypotensive and hypoxic. Lab work and a STAT chest X-ray were ordered. IV fluids were started. On 5/20/19, the IV line was taken out. The documentation supports that skilled nursing services were medically reasonable and necessary from 5/18/19 through 5/20/19. At that time, the enrollee had a medically complex condition, which needed daily monitoring and IV fluids. Daily skilled nursing care was not required prior to this nor was it required after May 20, 2019. The documentation does not support that the enrollee in this case needed skilled therapy services at an inpatient level on a daily basis in a skilled nursing facility. 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 SNF services provided from May 18, 2019 to May 20, 2019 have been met. Therefore, we decided that the Plan has to make payment for the SNF services provided from May 18, 2019 to May 20, 2019.
We also decided that the Plan does not have to make payment for the SNF care provided from May 10, 2019 to May 17, 2019 and from May 21, 2019 to June 8, 2019.
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 make payment for the SNF care provided from May 10, 2019 to May 17, 2019 and from May 21, 2019 to June 8, 2019. Our reviewer says daily skilled services were not required for dates before May 18, 2019 or after May 20, 2019, as per the above rationale. 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 SNF care provided from May 10, 2019 to May 17, 2019 and from May 21, 2019 to June 8, 2019 have not been met. Therefore, we decided that the Plan does not have to make payment for the SNF care provided from May 10, 2019 to May 17, 2019 and from May 21, 2019 to June 8, 2019.