Appeal type: SNF
Decision: Partially Favorable

We decided that the Plan has to pre-approve SNF services through April 17, 2021. We decided that the Plan does not have to pre-approve SNF services beginning April 18, 2021.

You asked the Plan to pre-approve SNF services through April 17, 2021. You say that these services are medically necessary. The Plan says that that the continuation of skilled services can be provided on an intermittent basis on an outpatient basis, in a long-term care facility, or in the home with home health care services.

We decided that the Plan has to pre-approve SNF services through April 17, 2021.

The Plan follows Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF services through April 17, 2021. Our reviewer says that SNF services are medically reasonable and necessary for the enrollee through April 17, 2021. The inpatient care at the skilled nursing facility was appropriate through April 17, 2021 due to the acute infection with COVID and the need for IV fluid management. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services through April 17, 2021 have been met. Therefore, we decided that the Plan has to pre-approve SNF services.

We also decided that the Plan does not have to pre-approve SNF services beginning April 18, 2021.

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 SNF services beginning April 18, 2021. Our reviewer says that SNF services are not medically reasonable and necessary for the enrollee beginning April 18, 2021. The member has stabilized medically and no longer was receiving skilled care as of April 17, 2021. He is not receiving skilled rehab as he has been determined to be at his functional baseline. He is no longer requiring skilled, complex wound care daily. Although the member does not have any skilled nursing needs, he continues to require custodial care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services beginning April 18, 2021. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services beginning April 18, 2021 have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services beginning April 18, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.