Appeal type: SNF
Decision: Partially Favorable

 
You asked the Plan to pay for SNF care. You say that you have a right to pursue payment for these services. 
The Plan says that the denial of payment for Skilled Nursing Facility (SNF) care is correct. 
 
We decided that the Plan has to pay for SNF care from April 7, 2020 to April 12, 2020.  
 
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 pay for SNF care. Our reviewer says that the SNF 
care provided from April 7, 2020 to April 12, 2020 meets the Medicare criteria for coverage. Our physician 
reviewer found the enrollee had daily skilled nursing needs that required the specialized skill, knowledge, and 
judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. Therefore, the enrollee required 
daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) 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 SNF level of care have been met. Therefore, we decided that the Plan has to pay 
for SNF care from April 7, 2020 to April 12, 2020.  
 
We also decided that the Plan does not have to pay for SNF care from April 1, 2020 to April 6, 2020. 
 
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 pay for SNF care. Our reviewer says that the SNF 
care provided from April 1, 2020 to April 6, 2020 does not meet the Medicare criteria for coverage. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing 
Facility (SNF) 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 SNF level of care have not been met. Therefore, we decided that the Plan does 
not have to pay for SNF care from April 1, 2020 to April 6, 2020. 
 
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.