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 admitted to acute care on 2/21/20 for right sided pleural effusion needing a chest tube. The enrollee's prior level of function is independent with front wheeled walker. At home, the enrollee lives with husband in trailer with 3 steps to enter. On 3/2/20, the enrollee discharged home as she was considered medically stable. Home health care services were set up. On 3/2/20 she needs supervision for transfers and bed mobility and ambulating 90 feet with supervision with front wheeled walker. On 3/3/20, the enrollee had instructions on how to care for chest tube site drainage. Telehealth was set up. The enrollee wears a life vest. Caregiver expresses resistance to changing dressing and general care. On 3/4/20, the enrollee's physician noted of wound with copious drainage. New wound orders given. There was no pain, no signs of infection, no undermining or tunneling, no odor. The enrollee indicated she will be going to Ohio on 3/24. On 3/7/20 the enrollee was still home with home health services. The enrollee states she is weak and needs a SNF. She said she is limited to do anything and has a leaking tube, swollen ankles and trouble standing. 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 in a SNF. The enrollee does not have a complex wound care or other SNF level skilled nursing need. This enrollee's functional level 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. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. 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).