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 SNF care is medically necessary. The Plan 
denied your request. The Plan says that the SNF care is not medically necessary, and the enrollee's needs can be 
met at a lower level of care such a long-term care facility with part-time skilled services. 
 
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 the enrollee has a medical history of left sided transtibial amputation, stroke in 
September of 2022 with dysphagia requiring G tube placement and left sided hemiparesis, gastroparesis, 
diabetes mellitus type II, hypertension, hyperlipidemia, and obesity. The enrollee was admitted to the hospital 
for fecal impaction, bloody emesis, and urinary tract infection. The record states the enrollee was living at 
home with her siblings and required assistance for transfers and mobility. She uses a manual wheelchair for 
mobility. An occupational therapy evaluation indicated that the enrollee could perform daily activities but 
required assistance. Currently, she is requiring maximum assistance with bed mobility and transfers and is non-
ambulatory. 
 
The enrollees conditions do require the level of observation, evaluation and treatment provided by a physician 
in the skilled nursing facility setting. She continues to have multiple issues that would benefit from physician 
oversight. While her G-tube was dislodged, the primary issue requiring hospitalization was hematemesis and 
she is at risk for blood loss. The enrollee does require skilled nursing services for tube feeding. 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. 
While she was requiring significant assistance with transfers and mobility prior to hospitalization, she has still had a decline in terms of her function and is not independent with bed mobility. She would benefit from skilled 
physical, occupational and speech therapy services to return her to her baseline level of function. 
 
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.