Appeal type: SNF
Decision: Partially Favorable

 
We decided that the Plan has to pay for the skilled nursing services provided from January 7, 2022, to January 
9, 2022. We decided that the Plan does not have to pay for the skilled nursing services provided from January 
1, 2022, to January 6, 2022, and from January 10, 2022, to January 27, 2022.  
 
You asked the Plan to pay for the skilled nursing services provided from January 1, 2022, to January 27, 2022. 
You say that the services which the enrollee required and received are coverable under the Medicare Act. The 
Plan says that the enrollee's condition no longer required daily skilled services at an inpatient skilled nursing 
facility (SNF) level of care. 
 
We decided that the Plan has to pay for the skilled nursing services provided from January 7, 2022, to 
January 9, 2022.  
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a skilled nursing facility 
(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 pay for the skilled nursing services provided from 
January 7, 2022, to January 9, 2022. Our reviewer says that the enrollee meets the Medicare criteria for SNF 
care for these dates of service. Our physician reviewer found the enrollee was lethargic and dehydrated and 
received intravenous hydration during these dates of service. Our reviewer also found that the enrollee meets 
the criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing services provided from January 7, 2022, to January 9, 2022. 
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 pay for the skilled nursing services provided from January 7, 2022, 
to January 9, 2022.  
 
We also decided that the Plan does not have to pay for the skilled nursing services provided from 
January 1, 2022, to January 6, 2022, and from January 10, 2022, to January 27, 2022. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a skilled nursing facility 
(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 pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care from January 1, 2022, to January 6, 2022, 
and from January 10, 2022, to January 27, 2022. 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 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 the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from January 1, 2022, to January 6, 2022, 
and from January 10, 2022, to January 27, 2022.  
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.