Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Obstructive Pulmonary Disease

Treatment: Skilled nursing facility (SNF) long term custodial care

The insurer denied coverage for skilled nursing facility (SNF) long term custodial care

The denial is overturned

This is an adult with a complicated past medical history. The patient stayed at a skilled nursing facility (SNF) for an extended period of time. This request is for review of medical necessity for the stay at a SNF. The previous request was denied due to missing documentation.      

Per Werner et al., "Among Medicare beneficiaries eligible for post-acute care at home or in a skilled nursing facility, discharge to home with home health care was associated with higher rates of readmission, no detectable differences in mortality or functional outcomes, and lower Medicare payments."

"Finally, our findings have implications for practice and research about patient- and family- centered care-teams in SNFs. Consistent with earlier studies, our findings suggest the need to cultivate formal and informal care-team interactions among physicians, nurses, rehabilitation therapists and social workers who directly prepare patients for transitions in care" (Toles, M., Colon-Emeric, C., & Naylor, M. D., et al., 2016).

Per Cao, Y., et al. (2022), "The study provides insight that could help identify high-risk persons for inclusion in future clinical interventions to prevent or delay SNF admissions among older beneficiaries in the US. We identified those at higher-risk by the following characteristics: non-Hispanic white, living alone, not being Medicaid eligible, frailty, and being cognitively or functionally impaired. This suggests that beneficiaries with these characteristics may need more support and guidance to live at home after a hospitalization. By applying the joint modeling approach with three outcomes in comparison to conventional single outcome models, we furthermore identified that SNF admission evidenced a strong positive correlation with hospitalizations, but SNF admission only evidenced a weak positive correlation with informal caregiving hours received after adjusting for important risk factors. Our findings suggest that the number of hospitalizations (medically-driven SNF care needs) evidenced a stronger positive correlation with SNF admission compared to informal caregiving hours received. This is an important and novel finding because SNF admission often is a consequence of a complex interplay between hospital discharge decisions considering the need, cost, and access to informal care. In conclusion, we identified a strong positive correlation between SNF admission and hospital admissions, but not between SNF admission and informal caregiving hours received after taking important risk factors into account. Beneficiaries, who were non-Hispanic white, living alone, and not Medicare-Medicaid dual eligible and frail, as well as beneficiaries with Alzheimer's disease related dementias (ADRD) and functional disabilities evidenced an increased risk of SNF admission. Apart from cohabitation status, these factors and lower levels of education were risk factors for any and/or number of hospital admissions. Medicaid eligibility was the only characteristic that was not associated with receipt or number of informal caregiving hours."

Given the complexity and severity of this individual's medical conditions, the skilled nursing facility was medically necessary.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for skilled nursing facility (SNF) long term custodial care is substantiated.