Appeal type: SNF
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care from February 22, 2023, 
through March 5, 2023. We decided that the Plan does not have to pre-approve SNF care from January 27, 
2023, through February 21, 2023.  
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan says that the requested admission to a SNF is not medically necessary. 
 
We decided that the Plan has to pre-approve SNF care from February 22, 2023, through March 5, 2023.  
 
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 
service is medically necessary. Our physician reviewer found the enrollee did qualify for SNF coverage from 
February 22, 2023, through March 5, 2023. During this period, the enrollee was being managed for a urinary 
tract infection and dehydration. A provider was evaluating the enrollee frequently. Laboratory studies were 
being monitored. The enrollee was receiving antibiotics. The enrollee was receiving fluids via various 
means. The provided care exceeded long-term care levels and met the definition of skilled care.  
 
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. Therefore, we decided that the Plan has to pre-approve 
SNF care from February 22, 2023, through March 5, 2023.  
 
We also decided that the Plan does not have to pre-approve SNF care from January 27, 2023, through 
February 21, 2023. 
 
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 from January 27, 2023, 
through February 21, 2023. Our reviewer says that the service is not medically necessary. Our physician 
reviewer found the enrollee did qualify for SNF coverage from February 22, 2023, through March 5, 2023. 
During this period, 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 care from January 27, 2023, through February 21, 2023, have not been 
met. Therefore, we decided that the Plan does not have to pre-approve SNF care from January 27, 2023, 
through February 21, 2023. 
   
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.