Description:
A skilled nursing facility is an institution which provides short-term, non-acute and extended care. This service could be postoperative or therapeutic for the acute and/or chronically ill. This facility must meet all of the following requirements: (a) maintain permanent and full-time facilities for bed care of resident patients; (b) have available at all times the services of a physician; (c) have a registered nurse (RN) or physician on full-time duty in charge of patient care, and one or more registered nurses or licensed practical nurse (LPN) on duty at all times; (d) maintain a daily medical record for each patient, (e) primarily be engaged in providing continuous skilled nursing care for sick or injured persons during the convalescent stage of illness or injuries and is not, other than incidentally, a rest home or a home for custodial care for the aged; and (f) operates lawfully as a nursing home in the jurisdiction where it is located. However, the institution cannot be primarily engaged in the care and treatment of drug addiction or alcoholism. 

Policy:
Admission to a skilled nursing facility is considered MEDICALLY NECESSARY when the following criteria are met: 

• The member has an illness severe enough to require constant or frequent skilled nursing care on a 24-hour basis that cannot be safely, efficiently, or effectively provided in a home environment or outpatient basis.

• The member is currently receiving inpatient hospital care, inpatient sub acute care, or home skilled nurse visits exceeding 2 or more visits per day.

• The admission to a skilled nursing facility will take the place of an admission to or continued stay at a hospital or sub acute facility.

• There is an expectation of sufficient improvement in the member's condition within a reasonable period of time that would permit the member to be discharged home.

Up to 7 calendar days* on an initial request. 

For ALL continued stay reviews, the facility needs to provide the following information: discharge plan including anticipated date of discharge and progress towards goals including the current functional status.

Anytime a SNF stay exceeds 30 calendar days the case must be reviewed by the medical director for medical necessity review for continuation of stay.

MD review is required for all continued stay requests after 30 days is approved.

CUSTODIAL CARE: This is considered a NOT MEDICALLY NECESSARY covered benefit.

Custodial care is defined as care primarily for maintenance of the member, designed to assist the member in the activities of daily living, and is not primarily provided for its therapeutic value in treatment of an illness, disease, bodily injury, or condition. Services considered custodial care include, but are not limited to, the following:

1. Help with activities of daily living, walking, bathing, dressing, toileting and/or feeding

2. Preparation of special diets

3. Supervision of self-administration of medications

Guidelines
Benefits for skilled nursing facilities include those services and supplies that are usually provided by a hospital to an inpatient, for example:

1. Registered or licensed practical nurse care.

2. Physical, occupational, speech, respiratory therapy.

3. Medical social service and comprehensive discharge planning.

4. Nutritional guidance and supplemental nourishment.

5. Limited diagnostic services.

6. Drugs prescribed by a physician.

7. Medical and surgical supplies.

8. Oxygen and its administration.

9. Durable medical equipment (DME), standard.

LEVELS OF CARE

STANDARD SERVICES INCLUDED IN ALL LEVELS:

• Semi-private rooms

• 24 hour nursing service/supplies

• Pharmacy: routine medications/supplies/supplemental nourishment

• Dietary/nutritional services

• Routine oxygen

• Laboratory tests and services, including interpretation

• Radiology tests and services, including interpretation

• Standard DME (durable medical equipment)

• Family/caregiver/patient education

• Social Services and comprehensive discharge planning

• Preadmission assessments

• Comprehensive, interdisciplinary care planning

• Written treatment and therapy evaluations provided to a  care manager or medical director within 72 hours of admission, as indicated

• Measurable clinical goals, including realistic time frames

• On-site care plan meetings with the care management teams, as indicated

• Progress evaluations, as requested by a  care manager

• Quality assessment and improvement program

• Transportation 

Level I

• Standard services only

Level II 

• All standard services listed above

• Therapy evaluations (physical, occupation, speech) as indicated upon admission

• Therapy treatments: up to two hours per day, five days per week

• Education: by nursing and/or rehabilitation staff

• Wound care: up to 2 treatments per day, single site, surgical, amputation, burns, decubitus — Stage 3 or greater

• Pain management

• Diabetic management

• Colostomy, ilcostomy, suprapubic catheter care: peritoneal dialysis

• Hospice care: respite, PO pain management

• Tracheostomy: stable 

• Direct admits from operating room with CAD or SQ pump 

Level III 

• All standard services listed above

• Comprehensive therapy treatments: up to three hours per day. five days per week

• Education: by nursing and/or rehabilitation staff

• IV infusion, peripheral line maintenance/supplies

• Enteral nutrition and related supplies

• Wound care: two or more treatments daily or multiple sites requiring debridement, packing, sterile technique, whirlpool, or management of drainage tubes

• Trachcostomy: suctioning two times per shift, unstable

• Post-traumatic injury, neurologically stable

• Oxygen: high concentration, nebulizer mist

• Respiratory therapy: one-two treatments daily, seven days per week

• Hospice care: respite, IV pain management, palliative treatment

• Pain management

Level IV 

• All standard services listed above

• 24-hour licensed respiratory therapy care

• Total ventilator and respiratory care, supplies, and equipment

• Weekly visits by managing pulmonologist

• Comprehensive therapy treatments: up lo four hours per day, seven days per week

• IV infusion, peripheral line, and pump maintenance and supplies

• Enteral nutrition and related supplies

• Isolation for infection control, private room

• Severe burns

• Complex wound care, multiple sites 

*Note: These services may require separate authorization or approval.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

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