Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission 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 enrollee is living at home after refusing 24/7 placement from the acute hospital, where he has two recent acute stays primarily social in nature. He is currently living at home with a decline in function. His most recent hospitalization was from 12/27/2019-1/2/2020 for delirium and dementia, which has worsened considerably after the recent death of his wife, who had dementia and was his main focus at home. The enrollee's prior level of function includes living at home with constant supervision from his son-in-law. Current function as documented in the hospital paperwork from late December/early January suggesting a need for 24-hour monitoring due to worsening dementia. The most recent therapy evaluation reveals the enrollee is walking 90 feet with a 2 wheeled walker and minimum assistance but showed decreased safety awareness and was inconsistent with following commands, requiring cues for all activities. A PCP note dated 1/23/20 stated the enrollee's pneumonia resolved on antibiotic. The enrollee was reported to be with dementia and behavioral issues and verbally abusive with alcohol intoxication recently. Physician notes he needs to be admitted to the VA facility next week. 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. The enrollee does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. This enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not require these skillednursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.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-approveadmission to a skilled nursing facility (SNF).