Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.You asked the Plan to pre-approve the 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 requested continuation of SNF care 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 the continuation of skilled nursing facility (SNF) care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member was admitted after falling and sustaining a thoracic compression fracture. Her relevant past medical history includes osteoarthritis, spinal stenosis, weakness, hypertension, hyperlipidemia, gastroesophageal reflux disease, and chronic pain syndrome. The member lives alone in a mobile home with ramp access and had been independent. As of 02/14/2020 she had pain being treated with fentanyl and Percocet. A back brace was being recommended when out of bed. Functionally, as of 02/17/2020 she was independent in bed mobility and transfers and required supervision when ambulating 200 feet with a Rollator walker. She required contact-guard assistance when negotiating stairs. She had good balance and good endurance. She required up to minimal assistance for lower body bathing and dressing. The therapy report indicates that she can walk distances in her home without an assistive device as the Rollator will not maneuver in her home.
Based on the documentation, the member is status-post thoracic compression fracture after falling as described above. The member has pain which needs to be assessed and treated. The member requires oversight of her medical conditions and medication management. She is at risk for further fall related injuries. The member has not returned to her prior level of function. The member requires physical therapy for progression of her mobility at a community level and to establish a maintenance home exercise program. An occupational therapy evaluation is indicated to assess the need for any adaptive equipment. There are skilled needs, but they do not need to be provided on a daily basis. The member is ambulating greater than household distances and 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. The member's care can be appropriately provided through home-based and outpatient services with intermittent scheduled services for lower body activities of daily living if needed.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, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.