Appeal type: SNF
Decision: Partially Favorable

 
We decided that the Plan has to pay for the skilled nursing services provided from January 8, 2019 to January 
9, 2019. We decided that the Plan does not have to pay for the skilled nursing services provided from January 
10, 2019 to January 20, 2019.  
 
You asked the Plan to pay for the skilled nursing services provided from January 8, 2019 to January 20, 2019. 
You say that the services which the enrollee required and received are coverable under the Medicare Act. The 
Plan says that the enrollee's condition no longer required daily skilled services at an inpatient SNF level of care. 
 
We decided that the Plan has to pay for the skilled nursing services provided from January 8, 2019 to 
January 9, 2019.  
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal. 
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered and 
signed two or more days before January 7, 2019. The Plan must pay for SNF services until the 100-day SNF 
care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. The NOMNC 
was signed by the enrollee's power of attorney on January 7, 2019, acknowledging that they had been notified. 
Based on this information, we decided that Medicare rules for coverage of the skilled nursing services provided 
from January 8, 2019 to January 9, 2019 have been met. Therefore, we decided that the Plan has to pay for the 
skilled nursing services provided from January 8, 2019 to January 9, 2019.  
 
We also decided that the Plan does not have to pay for the skilled nursing services provided from 
January 10, 2019 to January 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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 skilled nursing services have not been met. Based on this information, we 
decided that Medicare rules for coverage of the skilled nursing services provided from January 10, 2019 to 
January 20, 2019 have not been met. Therefore, we decided that the Plan does not have to pay for the skilled 
nursing services provided from January 10, 2019 to January 20, 2019. 
 
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.