Appeal type: SNF
Decision: Partially Favorable

 
We decided that the Plan has to pay for the skilled nursing facility (SNF) services billed with PDPM Score 
KACD1 x 11 days. We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services 
billed with PDPM Score KACD1 for the full 11 days.   
You asked the Plan to pay for the skilled nursing facility (SNF) services billed with PDPM Score KACD1 x 11 
days. You say that you would like the plan to reconsider their denial. The Plan says that the services billed are 
not supported by the documentation. 
 
We decided that the Plan has to pay for the skilled nursing facility (SNF) services billed with PDPM 
Score KACD1 x 7 days.  
 
The Plan follows Medicare rules. Medicare rules say that skilled nursing facility (SNF) services are to be 
reported with the appropriate PDPM Score.  
 
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 facility (SNF) services 
billed with PDPM Score KACD1 x 11 days. Our reviewer says that the documentation does not support the 
billing of the skilled nursing facility (SNF) services billed with PDPM Score KACD1 x 11 days. Our physician 
reviewer found the enrollee's chest X-ray was positive for pneumonia, and the enrollee was treated with an oral 
antibiotic until April 24, 2020. The Nursing note dated April 20, 2020 documents that the enrollee was on 
contact and airborne precautions due to fever beginning that day. On April 24, 2020 a clarification order is 
written that enhanced droplet/contact precautions secondary to temperature were to be in effect for seven days. 
It is noted that the enrollee was to remain within room at all times. Enhanced droplet precautions were 
discontinued on April 27, 2020. The clinical documentation received supports coding of isolation. The 
documentation supports that the enrollee had an active infection meeting CMS's RAI Manual coding 
requirements for isolation. Therefore, the documentation supports the billing of PDPM Score KACD1 x 7 days 
(April 20, 2020 to April 27, 2020).  
 
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 facility (SNF) services billed with PDPM Score KACD1 x 
11 days have been met. Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) 
services billed with PDPM Score KACD1 x 7 days.  
 
We also decided that the Plan does not have to pay for the skilled nursing facility (SNF) services billed 
with PDPM Score KACD1 for the full 11 days. 
 
The Plan follows Medicare rules. Medicare rules say that skilled nursing facility (SNF) services are to be 
reported with the appropriate PDPM Score. 
 
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 facility (SNF) services 
billed with PDPM Score KACD1 x 11 days. Our reviewer says that the documentation does not support the 
billing of the skilled nursing facility (SNF) services billed with PDPM Score KACD1 x 11 days. Our physician 
reviewer found the enrollee's chest X-ray was positive for pneumonia, and the enrollee was treated with an oral 
antibiotic until April 24, 2020. The Nursing note dated April 20, 2020 documents that the enrollee was on 
contact and airborne precautions due to fever beginning that day. On April 24, 2020 a clarification order is 
written that enhanced droplet/contact precautions secondary to temperature were to be in effect for seven days. 
It is noted that the enrollee was to remain within room at all times. Enhanced droplet precautions were 
discontinued on April 27, 2020. The clinical documentation received supports coding of isolation. The 
documentation supports that the enrollee had an active infection meeting CMS's RAI Manual coding 
requirements for isolation. Therefore, the documentation supports the billing of PDPM Score KACD1 x 7 days 
(April 20, 2020 to April 27, 2020).  
 
 
 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 facility (SNF) services billed with PDPM Score KACD1 x 
11 days have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing 
facility (SNF) services billed with PDPM Score KACD1 for the full 11 days. 
 
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.