Appeal type: SNF
Decision: Partially Favorable

We decided that the Plan has to pay for the skilled nursing services provided from September 1, 2019 to September 2, 2019. We decided that the Plan does not have to pay for the skilled nursing services provided from September 3, 2019 to September 30, 2019.
You asked the Plan to pay for the skilled nursing services provided from September 3, 2019 to September 30, 2019. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan says that the enrollee did not have daily skilled nursing or rehabilitation needs that required an inpatient stay at a SNF.
We decided that the Plan has to pay for the skilled nursing services provided from September 1, 2019 to September 2, 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 two or more days before August 31, 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. Therefore, we decided that the Plan has to pay for the skilled nursing services provided from September 1, 2019 to September 2, 2019. Therefore, we decided that the Plan has to pay for the skilled nursing services provided from September 1, 2019 to September 2, 2019.
We also decided that the Plan does not have to pay for the skilled nursing services provided from September 3, 2019 to September 30, 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 provided from September 3, 2019 to September 30, 2019. 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 provided from September 3, 2019 to September 30, 2019 have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from September 3, 2019 to September 30, 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.