Coverage Policies

Effective Date:

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Care in a skilled nursing facility requires preauthorization.

Most plans have a limited number of skilled nursing facility days available annually; refer to your plan documents.

Skilled nursing facility (SNF) services are medically necessary when ALL of the following criteria in Section A are met and one or more of the criteria in Section B are met:

Section A:

1. The individual requires skilled nursing or skilled rehabilitation services that must be performed by, or under the supervision of, professional or technical personnel; and
2. The individual requires these skilled services on a daily basis; (note: if skilled rehabilitation services are not available on a 7-day-a-week basis, an individual whose inpatient stay is based solely on the need for skilled rehabilitation services would meet the "daily basis" requirement when he/she needs and receives those services at least 5 days a week); and
3. As a practical matter, the daily skilled services can be provided only on an inpatient basis in a skilled nursing facility (SNF) setting; and
4. SNF services must be furnished pursuant to a physician`s orders and be reasonable and necessary for the treatment of an individual`s illness or injury (i.e., be consistent with the nature and severity of the individual`s illness or injury, his particular medical needs and accepted standards of medical practice; and
5. Initial admission and subsequent stay in a SNF for skilled nursing services or rehabilitation services must include development, management and evaluation of a plan of care as follows:
   1. The involvement of skilled nursing personnel is required to meet the individual`s medical needs, promote recovery and ensure medical safety (in terms of the individual`s physical or mental condition); and
   2. There must be a significant probability that complications would arise without skilled supervision of the treatment plan by a licensed nurse; and
   3. Care plans must include realistic nursing goals and objectives for the individual, discharge plans and the planned interventions by the nursing staff to meet those goals and objectives; and
   4. Updated care plans must document the outcome of the planned interventions; and
   5. There must be daily documentation of the individual`s progress or complications. 

Section B:

1. Observation, assessment and monitoring of a complicated or unstable condition.
   1. A complex or unstable condition of the individual must require the skills of a licensed nurse or rehabilitation personnel in order to identify and evaluate the individual`s need for possible modification of the treatment plan or initiation of additional medical procedures.
   2. There must be a high likelihood of a change in an individual`s condition due to complications or further exacerbations.
   3. Daily nursing or therapy notes must give evidence of the individual`s condition and documentation must indicate the results of monitoring.
      OR
2. Complex teaching services to the individual or caregiver requiring 24-hour SNF setting vs. intermittent home health care setting.
   1. The teaching itself is the skilled service. The activity being taught may or may not be considered skilled.
   2. Documentation should include the reasons why the teaching was not completed in the hospital, as well as the individual`s or caregiver`s capability of compliance
      OR
3. Complex medication regimen
   1. The individual must have a complex range of new medications (including oral medications) following a hospitalization where there is a high probability of adverse reactions or a need for changes in the dosage or type of medication.
   2. Documentation required to authorize initial admission and extensions must include the individual`s unstable condition, medication changes and continuing probability of complications.  Documentation also includes the individual’s progression in meeting goals or improvement in condition.

OR 

1. Initiation of tube feedings
   1. Nasogastric tube and percutaneous tubes (including gastrostomy and jejunostomy tubes).
      OR 
2. Active weaning of ventilator dependent individuals
   1. These individuals are considered skilled due to their complex care.
      OR 
3. Wound care (including decubitus/pressure ulcers)
   NOTE: Skilled nursing facility placement solely for the purpose of wound care should be rare.
   All of the following criteria must be met:
   1. Wound care must be ordered by a physician; and
   2. The individual must require extensive wound care (e.g., packing, debridement or irrigation of multiple stage II, or one or more stage III or IV pressure ulcers); and
   3. Skilled observation and assessment of a wound must be documented daily and should reflect any changes in wound status to support the medical necessity for continued observation.

Pressure Ulcer Stages

Suspected Deep Tissue Injury:
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
Further description:
Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

Stage I:
Intact skin with non-bleachable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
Further description:
The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons (a heralding sign of risk)

Stage II:
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.
Further description:
Presents as a shiny or dry shallow ulcer without slough or bruising.* this stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.
*Bruising indicates suspected deep tissue injury

Stage III:
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Further description:
The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

Stage IV:
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.
Further description:
The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.

Unstageable:
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
Further description:
Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body`s natural (biological) cover" and should not be removed.

Pressure Ulcer (National Pressure Ulcer Advisory Panel, 2007)

A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.

NOTE: The need for respiratory therapy, either by a nurse or by a respiratory therapist, does not alone qualify an individual for skilled nursing facility (SNF) care.

Not Medically Necessary:

A skilled nursing facility (SNF) setting is considered not medically necessary when ANY ONE of the following is present:

1. Services do not meet the medically necessary criteria above; or
2. The individual`s condition has changed such that skilled medical or rehabilitative care is no longer needed; or
3. Physical medicine therapy or rehabilitation services in which there is not a practical improvement in the level of functioning within a reasonable period of time; or
4. Services that are solely performed to preserve the present level of function or prevent regression of functions for an illness, injury or condition that is resolved or stable; or
5. The individual refuses to participate in the recommended treatment plan; or
6. Care is initially or has become custodial; or
7. The services are provided by a family member or another non-medical person. When a service can be safely and effectively self-administered or performed by the average non-medical person without the direct supervision of a nurse, the service cannot be regarded as a skilled service; or
8. Required services can be safely provided in the home health setting.

The following services are examples of services that do not require the skills of a licensed nurse or rehabilitation personnel and are therefore considered to be not medically necessary in the skilled nursing facility setting unless there is documentation of comorbidities and complications that require individual consideration.

• Routine services directed toward the prevention of injury or illness
• Routine or maintenance medication administration. SNF admissions solely for the administration of routine or maintenance medications, including intravenous (IV), intramuscular (IM) and subcutaneous (SQ) medications are not considered skilled. Parenteral medication administration in medically stable members is most often managed in the home setting by a home health or home infusion therapy provider.
• Care solely for the administration of oxygen, IPPB (intermittent positive pressure breathing) treatments and nebulizer treatments
• Routine enteral feedings
• Routine colostomy care
• Custodial care by a licensed practical nurse (LPN) or registered nurse (RN)
• Emotional support or counseling
• Suctioning of the nasopharynx or nasotrachea. Suctioning daily or as needed (PRN) with occurrences less frequently than every four hours is not considered skilled.
• Administration of suppositories or enemas
• Routine foot and nail care
• Medically stable ventilator care that can be safely provided in an alternative setting
• Urinary catheters. The presence of a stable indwelling or suprapubic catheter, the need for routine intermittent straight catheterization or ongoing intermittent straight catheterization for chronic condition, catheter replacement or routine catheter irrigation does not qualify an individual for SNF placement unless other skilled needs exist.
• Heat treatment – wet or dry
  1. Whirlpool baths, paraffin baths or heat lamp treatments do not qualify an individual for care in a SNF.
  2. There may be a rare instance when a severely compromised individual with desensitizing neuropathies or severe burns requires skilled observation during the above treatments. These cases are to be reviewed on an individual basis. Documentation must support the medical necessity for such observation.

1)    Most plans have a limited number of skilled nursing facility days available; see your plan documents.

1)    The Wound, Ostomy and Continence Nurse (WOCN). Position statement: pressure ulcer staging. Revised August 2007. Available at: http://www.wocn.org/pdfs/WOCN_Library/Position_Statements/PressureUlcerStaging.pdf