Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that continuation of SNF care is medically necessary as 
the enrollee has developed a urinary tract infection. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for continued stay at the SNF. 
 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee is a 79-year-old with a medical history of COPD, anemia, 
hypertension, hyperlipidemia, obstructive sleep apnea, and dementia. She was initially hospitalized on 2 25 
2023 for atrial fibrillation, acute respiratory failure due to a chronic obstructive pulmonary disease (COPD) 
exacerbation and anemia requiring blood transfusion. The enrollee was transferred to a skilled nursing facility 
on March 2, 2023. The enrollee is currently requiring supplemental oxygen with 2L via nasal cannula. The 
enrollee was previously living in an assisted living facility and ambulated with the assistance of a walker. As of 
March 10, 2023, the enrollee was ambulating 45 feet with walker with stand by assistance to supervision. The 
enrollee required stand by assistance to supervision for bed mobility, transfers, grooming, and upper body 
dressing and bathing. The enrollee required minimal assistance for toileting, lower body dressing and bathing. 
The enrollees conditions did not require the level of observation, evaluation and treatment provided by a 
physician in the skilled nursing facility setting. As of March 10, 2023, the enrollee was medically stable and 
tolerating oral medications. The enrollee required supplemental oxygen via nasal cannula but was not out of 
breath or in respiratory distress. The enrollee did not require skilled nursing services, including administration 
of intravenous (IV) medication, bowel or bladder training, wound care, or tube feeding. The enrollee did not 
have the degree of medical complexity to necessitate care in skilled nursing facility setting. The enrollee also 
did not require the level of intensity of skilled therapy services provided in the skilled nursing facility setting. 
As of March 10, 2023, the enrollee was ambulating 45 feet with walker with stand by assistance to supervision. 
The enrollee required stand by assistance to supervision for bed mobility, transfers, grooming, and upper body 
dressing and bathing. The enrollee required minimal assistance for toileting, lower body dressing and bathing. 
The enrollee primarily required supervision and some assistance with lower body dressing, but this did not 
necessitate skilled therapy services in a skilled nursing facility setting. Therefore, the requested skilled nursing 
facility care after March 12, 2023, was not 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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.