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 enrollee meets Medicare criteria for the requested admission to a SNF. Our physician reviewer found the member underwent a left upper lobectomy/resection with lymph node dissection complicated by acute respiratory failure and aspiration pneumonitis requiring intubation. His relevant past medical history includes anxiety, arthritis, chronic obstructive pulmonary disease, gastroesophageal reflux disease, hyperlipidemia, kidney stones, stroke, and visual impairment. The member lives with his spouse in a single level residence with 2 steps to the entrance and had been independent. As of 02/17/2020 he was 11 days status-post surgery. He was having mild pain that was improving. He was requesting constant pain medications. The treatment plan included continuing suction via chest tube. As of 02/18/2020 he had complaints of low back pain rated at 10/10. He was able to perform bed mobility with standby assistance and transfer and ambulate with a 4 wheeled walker 150 feet with contact guard assistance. During the treatment he became anxious without oxygen. Restrictions included his left chest tube. He was allowed to ambulate without suction. He is also receiving speech therapy for dysphagia. The member is status-post surgery as described above and has a chest tube and has complaints of pain with decreased oxygen saturation during activities. The member continues to receive wound care. He has pain which needs to be assessed and treated. The member requires oversight of his medical conditions and medication management. He is at risk for aspiration and recurrent pneumonia. He also continues to be treated with a chest tube. The member has not returned to his prior level of function. The member requires physical therapy for progression of his mobility at a community level and to establish a maintenance home exercise program. The
member requires occupational therapy for remaining activities of daily living and adaptive equipment. Speech therapy is indicated for managing his swallowing impairment to try to decrease the risk of aspiration. The member requires at least daily skilled nursing services for managing his chest tube. 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 independently. 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.