Medicare Advantage

This policy uses coverage criteria developed solely based on applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents.​​

MEDICALLY NECESSARY

SKILLED NURSING FACILITY: SKILLED LEVEL OF CARE

Admission to a skilled nursing facility (SNF) for a skilled level of care is considered medically necessary and, therefore, covered when ALL of the following criteria are met:

• The individual is medically stable.
  
• The individual requires skilled nursing or skilled therapy services, which must be ordered by an eligible professional provider (i.e., physician, nurse practitioner, physician assistant), and requires the skills, knowledge, and judgment of skilled nursing or skilled therapy professionals, who must perform or supervise the provision of these services.
• The individual requires these skilled services on a daily basis.
  
• The services​, as a practical matter,​​ cannot be provided or are unavailable in a less-intensive setting, such as home, office, outpatient, or long-term care facility with intermittent skilled services.
  
• The frequency, quantity, and intensity of these services are necessary for the management of the individual's diagnosis, taking into consideration their medical needs and accepted standards of medical practice.
• The individual also meets the criteria listed in the Skilled Therapy Services and/or Skilled Nursing Services sections.
  

Note: In order for a service to be considered skilled, the service, due to its inherent complexity, is such that it can only be performed safely and/or effectively by or under the supervision of professional nursing or skilled therapy professional.

Skilled Level of Care ​for the Provision of Skilled Therapy Services
 
In addition to the above criteria listed for SNF, skilled level of care ​for the provision of skilled therapy services ​to improve or maintain, or to prevent or slow further deterioration of, the member's condition ​are considered medically necessary and, therefore, covered when ALL of the following criteria are met:   

Frequency and Intensity of Services:

• The individual requires skilled therapy at a frequency and intensity of, at a minimum, 1 to 2 hours per day, 5 days per week.

Complexity of Services:

• The services are of a level of complexity and sophistication​, or the condition of the individual ​​is such that ​the needed services can be safely and effectively performed ONLY by a therapist (or under the direct supervision of a therapist for physical or occupational therapy).  ​

Participation:

• The individual is willing and able to actively participate in therapy. 
  

• The individual requires at least minimum assistance (functional level) for at least one of the following:
• Transfers
• Ambulation for household distances (if <50 feet) and/or, if nonambulatory, wheelchair use at household distances (if <50 feet)
• Gait training and teaching of prosthesis care for individuals with a recent amputation 

Functional Assessment and Goals:

• An assessment of the individual's clinical condition was considered in developing goals of therapy that are reasonable and based on the individual's clinical condition.​
• The individualized assessment demonstrates that the specialized skills, knowledge, and judgement of a qualified therapist are necessary for the creation and/or performance of the skilled therapy plan
• There is an expectation that one of the following will be met: 
  
• ​the individual's functional capabilities will improve significantly in a reasonable and predictable period of time
  
• Skilled therapy services require the specialized skills, knowledge, and judgment of a qualified therapist for the creation and/or performance of a safe and effective maintenance program. ​
  
• Objective documentation of the most recent functional status and measured progress toward goals must be provided.
• The services must be considered by accepted standards of medical practice to be specific and effective treatment for the individual's condition. ​

Skilled Level of Care for the Provision of ​Skilled Nursing Services

In addition to the above criteria listed for SNF, skilled level of care for the provision of skilled nursing services to improve or maintain, or to prevent or slow further deterioration of, the member's condition is considered medically necessary and, therefore, covered when all of the following criteria are met:  

Frequency and Intensity of Services:

• Skilled nursing services must be needed and provided on a “daily basis," i.e., on essentially a 7-days-a-week basis.
  

• Treatment of decubitus ulcers or wounds, whose measurements demonstrate a severity rated at a stage three or worse and require complex wound care.  Examples of complex wound care include:
• weekly assessments required by a wound care specialist for consideration of sharp debridement of necrotic tissue
• treatment of nutritional impairment (albumin <3.0) with nutritional supplements or enteral supplemental tube feedings for profound malnutrition
• stage IV with bone involvement (osteomyelitis) and debridement of infected bone requiring 6 to 8 weeks of systemic antibiotics guided by bone cultures
• ulceration near anus with consideration of fecal diversion​

• Initiation of nasogastric tube feeding, gastrostomy, and jejunostomy feeding, or when documented complications exist. Enteral feedings must comprise at least 26% of daily calorie requirements and provide at least 501 mL of fluid per day.
  
• Administration of intravenous (IV) injection drugs in either of the following situations:
  
• Two or more medications are administered daily
• Medications administered two or more times per 24 hours​​
  

SKILLED NURSING FACILITY: SUBACUTE LEVEL OF CARE
 In addition to the above criteria​ for SNF, admission to a SNF for a subacute level of care is considered medically necessary and, therefore, covered when ALL of the following criteria are met: 

• The individual requires skilled nursing services at least 4 hours per day ​on a daily basis and/or 2 to 3 hours per day of skilled therapy (physical therapy and/or occupational therapy) on at least 5 days per week.
  
• The individual's medical condition is complex, requiring more than once-weekly professional provider (e.g., professional provider or physical therapist) assessment, intervention, care plan update.
  
• The individual must also meet the criteria listed in the Subacute Level of Care Nursing Services and/or Subacute Level of Care Skilled Therapy Services sections.​
  

​
In addition to the above criteria for SNF, subacute level of care for the provision of skilled therapy services is considered medically necessary and, therefore, covered when the following criteria​ are met:

• The individual ​requires skilled therapy services for 2 to 3 hours per day at least 5 days per week.​
  

Subacute Level of Care for the Provision of Skilled Nursing Services​

In addition to meeting the above​ criteria for SNF, subacute level of care for the provision of skilled nursing services is considered medically necessary and, therefore, covered for the following conditions​​/medical needs:

• ​Administration of ​IV injection drugs in either of the following situations:
• ​Two or more medications are administered daily (there must be at least one other required skilled service)​​​
  
• Medications administered greater than three times per 24 hours​
• Respiratory care for the following:
  
• Mechanical ventilation management/weaning
  
• High-flow oxygen management
• ​New oxygen therapy management requiring monitoring and frequent adjustments (there must be at least one other required skilled service)
  
• Wound care for the following:
  
• Postsurgical infected wounds requiring IV antibiotics and complex wound care
  
• ​Fistula drain management
  
• ​Management of chest tubes, nephrostomy tubes, suprapubic catheters, rectal tubes, Dobhoff tubes
  
• Daily lab testing requiring frequent IV medication adjustments (there must be at least one other required skilled service)
  
• Management of total parenteral nutrition (initial 7 days)
  
• Pain management with the following:
  
• ​​​Requires medication management (with adjustments), physical therapy, and/or occupational therapy
  

CONTINUED STAY: SKILLED NURSING FACILITY

Continued stay in an SNF is considered medically necessary and is therefore covered for an individual that continues to demonstrate the need for skilled services as described above or has a condition expected to be of a short-term nature that makes discharge unsafe when care cannot be provided at a lower level of care.​

NOT MEDICALLY NECESSARY

Admission​ or continued stay in a SNF for skilled or subacute levels of care for the provision of skilled therapy services and/or skilled nursing services is considered not medically necessary and, therefore, not covered for conditions such as, but not limited to, the following because the available published peer-reviewed literature does not support its use in the treatment of illness or injury:

• Individual refuses or is unable to participate in therapy and there are no other skilled needs.
• Individual no longer requires frequent adjustments of oxygen therapy or complex medications.
• ​Individual's maintenance care n​eeds can be addressed safely and effectively through the use of nonskilled individuals. ​
  

NOT COVERED

CUSTODIAL CARE  
Custodial care is care provided primarily to assist the individual in meeting their activities of daily living (ADLs)​​ and which is not primarily provided for its therapeutic value in the treatment of an illness, disease, bodily injury, or condition. Custodial care also includes health care–related services that do not require the skills of a licensed professional provider. Custodial care is not covered by the Company because it is a service not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

Examples of custodial care that assists the individual in their ADLs include:  

• ​Wa​​lking 
  
• Getting in and out of bed
• Preparing meals or special diets
• Feeding
  
• Toileting
• Bathing
• Dressing

The following are examples of health care services that generally do not require the skills of a licensed professional once training has been received by a skilled professional. These services can then be safely and effectively performed by nonmedical individuals unless rendered under certain circumstances where there are special medical complications in which skilled nursing or skilled therapy professionals are required to perform or supervise it or to observe the individual. In these cases, the complications and special services involved must be documented by professional providers' orders and notes as well as nursing or therapy notes.  

• Subcutaneous injections alone, including insulin injections alone (stable dose) in an individual with diabetes
  
• Administration or supervision of the administration of routine medications that are typically self-administered (such as but not limited to routine oral medications, eye drops, nebulizers, or ointments).
  
• General maintenance care of colostomy and ileostomy
  
• Routine administration of enteral feeding through a tube (nasogastric, gastrostomy, jejunostomy, or gastrojejunostomy) 
  
• Routine services to maintain satisfactory functioning of indwelling bladder catheters (this would include emptying and cleaning containers and clamping the tubing)
  
• Straight catheterization using a clean but nonsterile catheterization technique ​
  
• Dressing changes for uninfected postoperative wounds or chronic conditions
  
• Prophylactic and palliative skin care, including bathing and application of creams, or treatment of minor skin problems
  
• Routine care for incontinence, including use of diapers and protective sheets
  
• General maintenance care in connection with a plaster cast (skilled supervision or observation may be required where the individual has a pre-existing skin or circulatory condition or requires adjustment of traction)
  
• Routine care in connection with braces and similar devices​
  
• Use of heat as a palliative and comfort measure, such as whirlpool or steam pack
  
• Periodic turning and positioning in bed
  
• General supervision of exercises, which have been taught to the individual and the performance of repetitious exercises that do not require skilled therapy professionals for their performance. (This includes the actual carrying out of maintenance programs where the performances of repetitive exercises that may be required to maintain function do not necessitate a need for the involvement and services of skilled therapy professionals. It also includes the carrying out of repetitive exercises to improve gait, maintain strength or endurance; passive exercises to maintain range of motion in paralyzed extremities that are not related to a specific loss of function; and assistive walking.)
  

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

SNF care for skilled and subacute level of services: there must be documentation of the complexity of the service to be performed and the documentation must indicate that the services are appropriate in terms of duration and quantity, and that the services promote the documented therapeutic goals.

Recent (within the past 24 hours) documentation of the individual's condition must be provided and must include the following:

• Baseline functional status
• Current functional status from all therapies given
• Recent measured progress toward goals
• Rehabilitation potential
• Comorbid conditions
• Barriers to progress​