Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the skilled nursing facility (SNF) services provided from August 11,
2020, through August 31, 2020, billed with code NGXE1.
You asked the Plan to pay for the SNF services as billed. You say that it is felt this is billed correctly. The Plan
denied your request. The Plan says that this is not billed correctly.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan failed to provide a valid denial rationale for the HIPPS code billed on
this claim. The denial rationale indicates both that the documentation does not support the inclusion of
ulcerative colitis, Crohn's disease, or inflammatory bowel disease in Section I of the Minimal Data Set (MDS)
form, and also that the documentation does not support any of the usual functional abilities reported in Section
GG. We find that neither of these reasons supports adjustment of the billed HIPPS code.
Firstly, although the inclusion of ulcerative colitis or similar conditions may not be supported, the Plan failed to
show how the inclusion of this condition would change the case-mix for any of the disciplines. This condition
is not part of the decision tree for assigning the nursing case-mix and does not have a value that would increase
the NTA case-mix score. As such, though not supported, this condition does not have an effect on the amount
paid to the SNF for the services rendered.
In regard to the usual functional ability documentation, we find that the rationale is insufficiently specific and
does not point to any specific function that the Plan believes does not match what is documented on the MDS
form. It is noted that the MDS Rehab Data Report cannot be used to support assessment coding as it does not
indicate the reference period for assessment of the GG activities. The assessing clinician fills out the MDS
form and documents these usual functional abilities by reviewing several different sources gathered over the
first three days of the SNF stay. The fact that the Rehab Data Report was not signed by the clinician who
completes the MDS assessment is not material to whether the reported levels are supported. Without a specificargument as to why any one of the reported functional levels is incorrectly documented, we find that this is not
a valid rationale for which to adjust the case-mix grouping. Therefore, we decided that the Plan has to pay for
the skilled nursing facility (SNF) services provided from August 11, 2020, through August 31, 2020, billed
with code NGXE1.
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.