Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested SNF admission is medically 
necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for SNF 
admission. 
 
The Plan must follow 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 care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided there is no documentation that the enrollee 
requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional 
nurse are not required to safely and effectively provide medically necessary and reasonable treatment. Records 
do not document the need for intravenous medications, new tube feeding, or ostomy care or daily complex 
wound care or respiratory care.  
 
Based on the medical records provided this enrollee does require skilled therapy services, i.e., the specialized 
skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically 
necessary and reasonable treatment. The enrollee is currently functioning significantly below her recently 
reported baseline. Based on the medical records provided there is documentation that daily skilled services are 
required. The enrollee is walking much less than household distances with minimum to moderate assistance 
and is minimum assist x 2 for transfers and is maximum assist to dependent for activities of daily living. 
Provided records document a significant decline in the enrollees functional status compared to her recent 
baseline to necessitate daily inpatient skilled therapy services.  
 
Based on the medical records provided there is documentation that the enrollee requires the services on an 
inpatient basis in a skilled nursing facility setting. Records document the enrollee lives alone and is not safe to return to her apartment at this time due to her level of weakness and instability. 
 
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 care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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.