Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says 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 admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee admitted to acute care on January 20, 2020 after falling on ice. He was diagnosed with a fractured and subluxed patella. The enrollee had open reduction and internal fixation surgery on January 22, 2020. A physical therapy (PT) note from 1/23/20 indicated the enrollee was only complaining of "a little pain". He was tolerating weight bearing on his straight leg brace. His mental disability led to him not being able to comprehend the therapist's instructions. PT noted on 1/27/20 that the enrollee was stand-by assist for sit to stand and stand to sit. Gait was 120 feet x 2 with stand-by assist and wheeled walker. The enrollee is showing improved ambulation and less need for verbal queing to understand exercises and ambulate within base of walker as well as keep an appropriate speed. Occupational therapy (OT) noted on 1-27 that the enrollee was moderate independent for upper body and lower body dressing. A 1/25/20 progress note states the enrollee is medically stable with stable vital signs. He is noting to be progressing with the walker but needs a lot of prompting by
therapy. A 1/27/20 progress note indicates the enrollee is wearing the brace without difficulty and needs close monitoring to use his walker properly and to not take an inappropriate step or bear weight on the post op leg. This enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. This enrollee's functional status does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment only in a SNF. Additionally, the most recent therapy note reveals the enrollee is showing improved ambulation and less need for verbal queing to understand exercises and ambulate within base of walker as well as keep an appropriate speed. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a daily basis in a SNF. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility 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 admission to a skilled nursing facility (SNF) have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).