Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe continuation of skilled nursing facility (SNF) care.You asked the Plan to pre-approvethe continuation of skilled nursing facility (SNF) care. You say that the requested continuation of SNF care is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for continuation of SNF care.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 the continuation of skilled nursing facility (SNF) care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with a diagnosis of debility related to right knee post-surgical infection. The enrollee states he had his leg amputated in November 2019 and is unable to leave facility due to his inability to walk and because of the stay home order. He is partial weight-bearing to right lower extremity with immobilizer. As per 2/6/20 progress note, the enrollee has completed his intravenous antibiotics. Skin is dry and intact with anabrasion from the brace rubbing. Current treatment for the abrasion is using Medihoney and gauze daily. By 2/8/20 in physical therapy he needs minimal assistance x 2 with sliding board transfers, wheelchair mobility and is dependent with toilet transfers.He is unable to ambulate. In occupational therapy he is set up for upper body bathing and dressing and supervision for lower body bathing and dressing. He was noted to reach max potential given weight bearing status. He had surgery scheduled 3/25/20 but was cancelled due to COVID19. He remains partial weight-bearing with right lower extremity. 
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 beyond 2/8/20. The enrollee does not have new enteral feedings, complex wound care or other SNF level skilled nursing need. The enrollee's functional level of reaching max potential given weight bearing limitations do not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond 2/8/20. The skilled nursing or skilled therapy services (or a combination of these services) are not needed on a daily basis in a SNF beyond 2/8/20. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond 2/8/20.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continuation of skilled nursing facility (SNF) care have not been met.Therefore, wedecided that the Plan does not have to pre-approvethe continuation of skilled nursing facility (SNF) care