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 criteria for the requested admission to a SNF. Our physician reviewer found the member has a relevant past medical history of chronic hyponatremia, interstitial lung disease being chronically treated with prednisone, hypertension, and was brought for the evaluation of chest discomfort associated with dizziness and weakness. An EKG showed T wave inversion which was not new and troponin was negative. Her labs were normal except for mildly elevated white blood cell count attributed to prednisone use. She was found to have a right lower extremity wound/skin tear. The member had previously been able to ambulate at a modified independent level with a rolling walker. She lives in a house with 3 steps to the entrance and had received Home Health Aide services. She was evaluated for physical therapy on 02/25/2020. She was independent in bed mobility. She required moderate assistance with transfers using a gait belt and rolling walker. She had difficulty standing due to proximal lower extremity weakness. She was ambulating 12 feet with decreased strength and impaired balance. The member is status-post acute care admission as described above and is ambulating limited distances and requiring moderate assistance for transfers. The member continues to receive wound care. The member requires oversight of her medical conditions and medication management. 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. The member requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. The member requires both daily skilled therapy and nursing services. She is unable to ambulate household distances 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 at a modified independent level. 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.