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 was seen in an Emergency Room with cough, sputum production, and expiratory wheezing at a
nursing home facility. An x-ray showed findings of chronic obstructive pulmonary disease with right upper and
middle lobe suspicious for pneumonia. He received intravenous antibiotics, steroids, and bronchodilator
treatments. He was admitted on 01/7/20 and discharged on 01/13/2020. The enrollee is a long-term care
resident and had been able to function at a modified independent level. When evaluated for physical therapy he
was able to perform bed mobility and transfer independently. He required standby assistance when ambulating
150 feet with a front wheeled walker. In occupational therapy he required set up for upper and supervision for
lower body activities of daily living. He was seen for a speech therapy evaluation only with poor rehabilitation
potential as he was functioning at his baseline level.
The enrollee is status-post treatment for chronic obstructive pulmonary disease and pneumonia as described above without significant new impairing condition. The enrollee continues to require oversight of his medical conditions and medication management. He is at risk for further infections and chronic obstructive pulmonary disease exacerbations. The enrollee has not returned to his prior level of function. The enrollee requires either physical therapy or occupational therapy for endurance and for instruction in a home exercise program including rehabilitation pulmonary techniques. There are skilled needs, but they do not need to be provided on a daily basis. The enrollee is ambulating greater than household distances and performing essential activities of daily living without hands on assistance. The enrollee is receiving care that can be provided by his non-skilled caregivers with periodic skilled oversight and modification of the care plan if needed. The enrollee's condition would not be expected to deteriorate with services provided on a less than daily basis. The enrollee's care can be appropriately provided through home-based and outpatient services with intermittent skilled services on a less than daily basis. 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).