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 of recent deep vein thrombosis, Type II diabetes, hypertension, mood disorder, dementia, hyperlipidemia, cardiomyopathy, and a remote history of seizures who presented on 02/22/2020 with encephalopathy and dysarthria with right-sided neglect. Imaging showed findings of a left temporoparietal intracerebral hemorrhage with vasogenic edema and compression. She had intensive unit care. No neurosurgical intervention was recommended. She was started on seizure prophylaxis. She has a normal body mass index. The member lives with her husband in a single level home with 5 steps. Her husband is wheelchair-bound for most of the time and is unable to understand what his wife is saying due to aphasia. As of 03/12/2020 she was able to perform transfers with close supervision and ambulate 75 feet with a rolling walker. She had decreased gait speed. She was able to manage the walker well during turns. There was no overt loss of balance noted when ambulating. The member is status-post acute care admission as described above and has a primary impairment of aphasia after a new stroke. There are no skilled nursing needs. The member is not receiving IV medications or fluids. Routine monitoring of her 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 requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. Speech therapy is indicated for treating her a aphasia. 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 is receiving care that can be provided by her non-skilled caregivers with periodic skilled oversight and modification of the care plan if needed. The member's condition would not be expected to deteriorate with services provided on a less than daily basis. Her care can be continued at an alternate level. Consideration could be given to a home evaluation to see whether she is able to function better in her own, familiar environment. If she has home health services available and, if she is able to function better at home, home-based care with services may be an option for her. Alternatively, her care can be provided at a custodial level with intermittent skilled 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 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).