Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says that the requested admission to a SNF 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 to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the requested admission to a SNF is medically necessary. Our physician reviewer found the member has a history of a fall while residing at an assisted living facility when she was trying to get up on her own to use the bathroom. She had increasing back pain. She was seen in an Emergency Room with imaging showing findings of a chronic-appearing L4 compression fracture. The member was discharged and then was unable to get up with assistance and return to the Emergency Room. The member had previously required assistance x1 with all mobility and had been able to ambulate with a rolling walker daily. After she was initially discharged she was unable to get up with assistance x3. When evaluated she was able to follow single-step commands. Although she denied pain she was wincing with movements. She had decreased shoulder and bilateral lower extremity range of motion and there was decreased strength. She required maximum assistance for bed mobility and up to moderate assistance for transfers. When attempting to step forward she was only able to take a few small steps. She remained fearful of falling. She had retropulsion and was unsteady. The member had fallen as described above and had been unable to get up despite assistance of more than one person when she had returned to the assisted living facility. The member requires oversight of her medical conditions and medication management. She has cognitive impairment and would not be expected to be able to adjust medications or self-monitor her medical conditions. The member has pain which needs to be assessed and treated. Her pain management is complicated by her cognitive impairment. She is at risk for secondary complications of immobility such as pressure ulcers and contractures. The member has not returned to her prior level of function. She had previously been able to ambulate with assistance x1. The member requires physical therapy for mobility. The member requires both daily skilled therapy and nursing services.
She is unable to perform essential activities of daily living such as bed mobility or ambulate without assistance. The member's condition would be expected to deteriorate with services provided on a less than daily basis. The member had previously been able to function in an assisted living facility. There is a reasonable expectation of a reduction in burden of care with a goal of a successful return to the community through the SNF level care being requested. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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.