Skilled Nursing Facility Care denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility level of care and authorization and coverage for 60 days of assisted living care services after the enrollee has been discharged from skilled nursing facility for treatment of the enrollee who has a recent history of multiple fractures, respiratory failure and hypoxia. Findings: The physician reviewer found that The patient sustained multiple major soft tissue, respiratory system and orthopedic injuries due to a motor vehicle accident in late October 2017. The patient had a prolonged and complicated course in the critical care setting, undergoing multiple surgeries. The patient was medically stabilized by mid November 2017 and transferred to a skilled nursing facility at that time.

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for custodial care services. The records document that the patient was diagnosed with metastatic adenocarcinoma of the colon with metastasis to the liver. The patient underwent exploratory laparotomy with placement of diverting loop ileostomy for small bowel obstruction. The patient was then admitted to a skilled nursing facility (SNF). The patient’s functional status was contact guard assist (CGA) for bed mobility, transfers, and gait. At CGA level for gait and transfers, the patient may not have been suitable for home discharge depending on the level of supportive care available at home. It also appears that the discharge paperwork has listed home with family or caregiver versus board and care placement and home health as a discharge disposition plan.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for skilled nursing facility (SNF) level of care services.Admission to an 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 and daily skilled nursing services. Patients require daily 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. Services also include skilled nursing observation, such as regular monitoring of vital signs and skin in the setting of wounds, as well as intake and output. Patients typically benefit from daily skilled therapy services, including physical, occupational, and speech therapies.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility care. 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, as well as constantly available skilled nursing services. Patients 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. Patients also require skilled nursing observation, including 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 Care, then check the rights and deadlines that apply to your plan.