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 SNF care is medically necessary. The Plan denied 
your request. The Plan says that the records do not show that the enrollee needs more skilled therapy, more 
complicated medical care, complicated wound care that cannot be done by a nurse at home and that enrollee's 
needs cannot be met in another setting, such as at home, in a long-term care facility, or other outpatient setting. 
 
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 SNF 
care is medically necessary. Our physician reviewer found that the enrollee is 72-year-old male with a medical 
history of dementia, neurofibromatosis, atrial fibrillation, and hypertension. The patient was hospitalized on 7 
18 2022 for a right hip fracture after a fall. He underwent right hip arthroplasty. The patient was previously 
living in a long-term care facility. He is non-ambulatory and requires a wheelchair for mobility. He can 
perform transfers and needs some assistance with activities of daily living. A physical therapy assessment 
performed 7 21 2022 indicated that the patient required maximum assistance with bed mobility and transfers. 
An occupational therapy assessment indicated that the patient required moderate assistance for feeding, 
grooming, bathing, and dressing. 
 
The patients conditions do require the level of observation, evaluation and treatment provided by a physician 
in the skilled nursing facility setting. The patient is 72-year-old male with a medical history of dementia, 
neurofibromatosis, atrial fibrillation, and hypertension. The enrollee was hospitalized on July 18, 2022 for a 
right hip fracture after a fall. He underwent right hip arthroplasty. The enrollee does have the degree of medical 
complexity to necessitate care in skilled nursing facility setting. The enrollee also does require the level of 
intensity of skilled therapy services provided in the skilled nursing facility setting. Although he lives in an 
assisted living facility or long-term care facility, he has had a significant decline in function. While he was non-ambulatory and required a wheelchair for mobility, he could perform transfers and needed some assistance with 
activities of daily living. A physical therapy assessment indicated that the enrollee now requires maximum 
assistance with bed mobility and transfers. An occupational therapy assessment indicated that the enrollee 
requires moderate assistance for feeding, grooming, bathing, and dressing. Therefore, the requested skilled 
nursing facility care is medically necessary. 
 
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.