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 member has a relevant past medical history that includes lumbar spine surgery approximately 5 years ago. She was admitted with lower back pain beginning approximately 5 days before. She had gotten out of her chair and walked to the bathroom and when attempting to sit back down she had the sudden onset of back pain. She initially noted pain radiating to the left lateral leg and down her leg. A CT scan of the lumbar spine showed findings of a posterior lumbar instrumented fusion. There was possible hardware loosening. There were multilevel degenerative changes which were relatively stable since the prior exam. She was seen for a physical therapy evaluation on 03/08/2020. She was now having the same sensation down the right leg. The member lives in a mobile home with 4 steps to the entrance with her significant other who recently suffered a minor stroke and is unable to provide much assistance. Her significant other's daughter frequently visits. She had previously required assistance for stair negotiation when entering and exiting her home. When seen she had pain rated at 6/10. She had a forward head posture. She was able to perform bed mobility at a modified
independent level. She was able to perform transfers with supervision. She was able to ambulate 5 feet with a rolling walker with decreased cadence and decreased foot clearance requiring contact-guard assistance. She was able to ambulate from her bed to the doorway and requested returning to bed due to pain in the low back and lower extremities on the left greater than right side. The member is being treated for lower back pain with lower extremity symptoms as described above. There are no skilled nursing needs. The member is not receiving IV medications or fluids. Routine monitoring of her chronic medical conditions is being done such as assessment of pain, routine administration of oral medications, support of chronic physical debilities, and assessment of her skin condition. There are no unaddressed medical conditions or conditions that require complex monitoring or medication adjustments. 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 due to her acute low back and lower extremity pain. There are skilled needs, but they do not need to be provided on a daily basis. The member is performing essential activities of daily living without hands on assistance. The member's condition would not be expected to deteriorate with services provided 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).