Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe continuation of skilled nursing facility (SNF) care.You asked the Plan to pre-approvethe continuation of skilled nursing facility (SNF) care. You say that the requested continuation of SNF care is medically necessary.The Plan denied your request. The Plan says the requested continuation of SNF care 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 todetermine if the Plan was correct in denying the request to pre-approve the continuation of skilled nursing facility (SNF) care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted for acute care on 12/23/2019 with progressive weakness and treated for a urinary tract infection. His relevant past medical history includes a suprapubic catheter for chronic urinary retention, peripheral vascular disease, bilateral hip fractures, and chronic gait dysfunction. The enrollee lives alone in a residence with 3 steps to the entrance and had received 24-hour caregiver assistance. He had ambulated short distances with a cane/walker. As of 01/27/2019 he was able to ambulate over 170 feet with a rolling walker and contact-guard assistance. In occupational therapy he required set up for upper body bathing and moderate assistance for dressing. On 01/28/2020 he was ambulating over 200 feet. Nursing notes indicate drainage of yellow urine from the catheter andthe member as denying pain or shortness of breath. He is alert and oriented x2-3 with confusion at times. The enrollee is status-post treatment for urinary tract infection without recent injury or new impairing condition as described above. The enrolleerequires oversight of his medical conditions and medication management. He is at risk for further urinary tract infections. The enrollee requires physical therapy for progression of his mobility at a community level and to establish a maintenance home exercise program. An occupational therapy evaluation is indicated to assess the need for any adaptive equipment. There are skilled needs, but they do not need to be provided on a daily basis. The enrollee is ambulating greater than household distances and performing essential activities of daily living without hands on assistance.The enrollee is receiving care that can be provided by his non-skilled caregivers with periodic skilled oversight and modification of the care plan if needed and he has 24-hours caregivers available. The enrollee's condition would not be expected to deteriorate with services provided on a less than daily basis. The enrollee's care can be appropriately provided through home-based and outpatient services with intermittent skilled services on a less than daily basis.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 continuation of skilled nursing facility (SNF) care have not been met.Therefore, we decided that the Plan does not have to pre-approvethe continuation of skilled nursing facility (SNF) care.