Skilled Nursing Facility Admission denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient requested reimbursement and prospective authorization and coverage for long-term custodial care services.Admission to a skilled nursing facility (SNF) for skilled nursing services 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 require skilled nursing services, including wound management, tracheostomy care, bowel and bladder training, tube feeding, and administration of intravenous (IV) medications or medications that cannot be self-administered safely. Patients at the SNF level of care also require skilled nursing observation, including regular monitoring of vital signs, skin in the setting of wounds, and intake and output.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for skilled nursing facility (SNF) level of care. Findings: As noted in the medical literature, SNF admission may be indicated for patients with more than one wound, including a stage 3 pressure ulcer, rehabilitation, gait training, and observation. One study noted that, “Pressure ulcers (PUs) are injuries to the skin and underlying tissues that occur most commonly over bony prominences, such as the hips and heels as a result of pressure and shear forces.” Another study analyzed 477 patient records to determine the percentage of patients with pressure ulcers/injuries (PU/Is) who required admission to a SNF for wound care. The authors found that the majority of patients with a PU/I required admission from home to a SNF for appropriate care.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) skilled nursing level of care services and/or (2) physical therapy five times per week. Admission to a skilled nursing facility (SNF) is appropriate for patients with conditions requiring observation, treatment plan evaluation, and physician updating orders along with constantly available skilled nursing services. Skilled nursing services may include wound management, tracheostomy care, bowel and bladder training, tube feeding, and administering intravenous (IV) medications or medications that cannot be self-administered safely. Skilled nursing observation may include regularly monitoring vital signs, skin in the setting of wounds, and intake and output.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility level of care services. Admission to a skilled nursing facility is appropriate for patients with conditions that require observation, evaluation of treatment plans, and updating of orders by a physician along with constantly available skilled nursing services. Skilled nursing services may include wound management, tracheostomy care, bowel and bladder training, tube feeding, and the administration of intravenous (IV) medications or medications that cannot be self-administered safely. Skilled nursing observation may include regular monitoring of vital signs, skin in the setting of wounds, and intake and output.

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 Admission, then check the rights and deadlines that apply to your plan.