Skilled Nursing Facility denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services, including speech therapy, physical therapy, and occupational therapy. As noted in the medical literature, admission to SNF is appropriate for patients with conditions that require observation, evaluation of treatment plans, and updating of orders by a physician as well as constantly available skilled nursing services. Patients treated in a SNF require skilled nursing services including wound management, tracheostomy care, bowel and bladder training and tube feeding, and administration of intravenous (IV) medications or medications that cannot be self-administered safely.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services and/or acute rehabilitation facility services. Findings: The physician reviewer found that the documentation available for review, it is identified that the patient sustained an incomplete cervical spinal cord injury. Additionally, there is report of sensation and strength below the level of injury. The records suggest that the patient has not received bowel and bladder training, pressure relief training as evidenced by a stage 3 ulcer, training with activities of daily living, assistive device assessment and training, family training, or adequate rehabilitation with physical therapy and occupational therapy.

Where the denial was upheld

The enrollee is requesting authorization and coverage, and reimbursement, for skilled nursing facility (SNF) services. The enrollee was admitted to a skilled nursing facility (SNF) for the treatment of severe left hip osteoarthritis status post left total hip arthroplasty. The records indicate the enrollee received skilled physical therapy (PT)/occupational therapy (OT) services to enhance functional mobility skills and activities of daily living (ADLs). The enrollee was able to ambulate 35 feet with one rest period using a front wheel walker and requiring minimal assistance. Her physical status was touch down weight bearing. As part of the discharge plan, durable medical equipment, including a walker and home care referral were prescribed. However, the enrollee did not feel safe for home discharge because she was walking on tippy toes only, and could not walk.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for skilled nursing facility services from 5/15/21 through 5/22/21.The patient has had recurrent strokes deemed to be cardioembolic in nature, in the setting of chronic atrial fibrillation with high CHADS-VASC score. Each stroke was treated within a short timeframe, with rapid to early restoration of arterial flow, minimizing the extent of damage to the neuronal reservoir, which is the primary determinant of outcomes following stroke according to Alawieh and colleagues. By 5/14/21, the patient had 5-/5 strength on the left side and some mild functional deficits that could be further addressed with rehabilitation in the community setting. Continued stay in a skilled nursing facility in case he had another stroke was not a medical necessity.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Skilled Nursing Facility, then check the rights and deadlines that apply to your plan.