CurrentLA Care HealthPolicy N/A

Skilled Nursing Facility clinical guidelines

Defines L.A. Care Health clinical guidelines for assessing medical necessity, admission, continued stay, and certain ancillary services for skilled nursing and subacute facility care for L.A. Care members.

Policy Summary

PayerLA Care Health

PolicySkilled Nursing Facility clinical guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document daily skilled nursing and/or skilled rehabilitation treatments with an active written treatment plan.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24-hourinpatient skilled nursing availability minimum

BMI > 40obesity services threshold

>4 / hrsitter trigger frequency

dailyskilled treatments required

Coverage and Medical Necessity Criteria

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Initial and Continued Stay Criteria

Admission and continued stay are considered medically necessary when ALL of the following are met:

Primary conditions for SNF/subacute admission

Appropriate level justification: One or more of the following: meets criteria under one of the 4 L.A. Care Skilled Level of Care definitions; severity/complexity/intensity of skilled treatment(s) needed are beyond the capabilities of alternative levels of care; frequency of diagnostic and therapeutic services needed makes alternative levels impractical; lower level of care has already failed.
Skilled service characteristics: Services require the skills of licensed technical or professional personnel and must be provided directly by or under general supervision to assure safety and achieve the medically desired result; are not custodial in nature.

Skilled nursing indications (examples): Service required can only be performed safely and effectively by or under the general supervision of skilled nursing personnel; observation and assessment of the patient's changing condition requires skilled nursing to evaluate need for treatment.

Skilled procedures requiring skilled nursing (selected list): Includes IV infusion/injection/IM to resolve the acute admitting condition; initiation and ongoing titration of new enteral feedings or new TPN until stable; wound management for newly formed actively and progressively healing wounds requiring at a minimum daily dressing changes with prescription medication and aseptic technique; management of surgical drains or catheters (excluding Foley) requiring at least daily drainage; oxygen weaning and/or need for frequent nasopharyngeal or tracheostomy aspiration/suctioning or respiratory therapy >2x/day; patient care skills training and immediate post-operative new ostomy/suprapubic catheter/new diabetic insulin training; titration and daily dose adjustments of oral medications to optimize disease states.

Skilled rehabilitation criteria: Patient has an acute medical condition or acute exacerbation of a chronic condition causing decreased functional ability such that they cannot adequately recover without therapy; therapy must be reasonable and necessary and directly related to an active written treatment plan developed by physician and therapist (amount, duration, frequency); individual is expected and continues to show measurable functional improvement on a daily basis or services are necessary to establish a safe and effective maintenance program.

Enhanced Barrier Precautions

Enhanced Barrier Precautions should be considered medically necessary when ALL of the following are true:

EBP criteria: Resident has one or more qualifying conditions (e.g., unhealed wound(s) regardless of MDRO colonization status; indwelling medical devices such as central line, feeding tube, tracheostomy, ventilator) AND the facility demonstrates consistent use of appropriate personal protective equipment during all high-contact resident care activities (including bathing/showering, transferring, changing linens, assisting with toileting/changing briefs, device care, and wound care for chronic wounds).

Isolation

Additional services for isolation should be considered medically necessary when ALL of the following are true:

Isolation criteria: Use of a single room without cohorting; enhanced barrier precautions are not appropriate; and active or suspected infection with infectious agents transmitted by contact, droplet, or airborne routes as defined by CDC.

Obesity

Additional services for obesity should be considered medically necessary when BOTH of the following are true:

Obesity services: BMI > 40 AND functional level of substantial to maximum assist based on MDS.

Sitters

Sitters should be considered medically necessary when ALL of the following are true:

Sitter criteria: Member has a diagnosed Neurocognitive Disorder not due to an acute reversible cause; the disorder is not expected to improve; the member exhibits severe behavioral or aggressive disturbances due to poor impulse control; the behavior is not due to an underlying psychiatric diagnosis for which the member is receiving psychiatric care; treatment has been medically optimized with pharmacologic and nonpharmacologic approaches; and the member requires frequent nursing interventions (> 4 per hour) including redirection or behavior modification.

Services that are routine, custodial, maintenance, provided for preservation of present function, or that can be safely delivered in an outpatient setting are excluded from skilled nursing/subacute level coverage. Examples include routine medication administration (e.g., insulin, oral medications, eye drops), routine respiratory or nebulizer treatments for stable conditions, routine enteral feedings and/or TPN/PPN, routine colostomy care, and other routine catheter or wound care that can be managed outpatient. Documentation must show skilled-level complexity or supervision to override these exclusions.

A skilled nursing or subacute facility level of care is considered not medically necessary when any one of the specified conditions is present. Triggers for denial include, but are not limited to: services that do not meet the medical necessity criteria; patient not participating in the treatment plan (for example, not engaging in rehabilitation therapies or patient education); lack of practical improvement in function within a reasonable time; patient ambulatory for household distances with less than minimal assistance and able to perform activities of daily living with less than minimal assistance; services provided solely to preserve current function for a resolved or stable condition; or care that is primarily routine or preventive in nature.

Admission to Skilled Nursing / Subacute Facility

SNF | subacute — Admission criteria

Admission to SNF/Subacute: No acute hospital care needs identified; patient is stable for transfer; SNF/subacute level of care is more appropriate than lower levels of care as indicated by listed justifications; facility provides at minimum daily skilled nursing and/or skilled rehabilitation treatments; services require licensed skilled personnel and are not custodial.

Continued Stay Requirements

SNF | subacute — Continued stay criteria

Continued stay: Ongoing need for daily skilled nursing and/or skilled rehabilitation as ordered; therapy remains reasonable and necessary with amount/duration/frequency directly related to an active written treatment plan developed by physician and therapist; individual is expected and continues to show measurable functional improvement on a daily basis or services are necessary to establish a safe and effective maintenance program; skilled interventions or observation remain necessary.

Provider Requirements and Operational Notes

Prior Authorization

Prior Authorization Required

Prior authorization is required for admission to a skilled nursing facility (SNF) or subacute facility when skilled level of care is being requested. Admissions must meet L.A. Care criteria for skilled nursing or skilled rehabilitation: skilled services ordered by a physician, requiring licensed skilled personnel, not custodial, and where daily skilled nursing and/or skilled rehabilitation is necessary.

Applies to initial admission and continued stay requests
Facility must demonstrate the skilled level of care per L.A. Care established Skilled Level of Care agreement

Note

Provider Actions

Providers must follow operational requirements to support authorization and payment decisions. Ensure timely submission of all required orders, therapy plans, and progress notes; respond to requests for additional information promptly to avoid delays or denials.

Submit physician orders and the active written treatment plan developed by physician and therapist
Provide documentation of daily skilled nursing and/or skilled rehabilitation treatments

Documentation Required

Required Documentation

Documentation must clearly justify the need for skilled services. Physicians' orders and nursing or therapy notes must document the complications, special services, and skilled interventions required to support skilled SNF/subacute admission and continued stay.

Physician orders must specify skilled services required and frequency
Nursing and therapy notes must document clinical complications, skilled tasks performed, measurable functional progress, and daily skilled needs

Denial Risk

Triggers for Denial / Not Medically Necessary

Admissions and continued stays will be considered not medically necessary when any listed condition is present. Review these triggers before admission to avoid inappropriate placement and potential claim denials.

Services do not meet the skilled criteria (e.g., custodial care or care appropriate for a lower level of service)
Patient is not participating in the treatment plan (not engaging in therapies or patient education)
Patient has not shown practical improvement in function within a reasonable period
Patient is ambulatory/mobile for household distances with less than minimal assistance and can perform ADLs with less than minimal assistance
Services are solely to preserve current function or prevent regression for a condition that is resolved or stable
Care is primarily routine or preventive rather than requiring skilled intervention
Routine or maintenance medication administration (e.g., routine insulin, oral meds, eye drops, nebulization for stable conditions)
Care solely for administration of oxygen, intermittent positive pressure breathing, and/or nebulizer treatments for stable respiratory conditions
Routine enteral feedings and/or TPN/PPN provided as maintenance
Routine colostomy care

Key Coding Thresholds and Values

Obesity BMI threshold

Obesity BMI thresholdBMI > 40

Obesity services conditionFunctional level of substantial to maximum assist based on MDS

Policy triggerAdditional obesity services considered medically necessary only when BOTH criteria are met

Definitions

Custodial care — definition

DefinitionCare primarily for assistance with activities of daily living or meeting personal rather than medical needs (e.g., bathing, dressing, feeding, toileting, supervision of medication) that is not specific therapy for an illness or injury

Not skilled careDoes not require continuing attention or supervision of trained, licensed medical or paramedical personnel when individual has reached maximum level of function

ExamplesAssistance in walking, getting in and out of bed, preparation of special diets

Enhanced Barrier Precautions (EBP) — definition

DefinitionAdditional infection control techniques to reduce transmission of multidrug-resistant organisms (MDROs) that require use of gown and gloves during high-contact resident care activities

High-contact activitiesIncludes dressing, bathing/showering, transferring, changing linens, changing briefs or assisting with toileting, device care or use, wound care for chronic wounds, and therapy

PurposeApplied for residents who may be infected, colonized, or at high risk for colonization to limit MDRO spread

Isolation — definition

DefinitionPlacement of residents in single bedrooms without cohorting, with infected residents required to wear well-fitting masks when outside the room and health care personnel using at minimum gloves and gowns upon every room entry and for all care interactions

CohortingCohorting patients does not constitute isolation

IndicationsUsed when enhanced barrier precautions are not appropriate and for active or suspected infections transmitted by contact, droplet, or airborne routes per CDC

Neurocognitive Disorder — definition

DefinitionA disease, illness, or condition causing a significant decline in mental abilities and cognition representing marked deterioration from prior level of function

Associated conditionsMay include traumatic brain injury, stroke, cardiovascular or metabolic disorders, infectious causes, chronic low oxygen, and neurodegenerative diseases such as Huntington's, Parkinson's, Alzheimer's, or Lewy Body Dementia

Clinical implicationRepresents substantial cognitive impairment impacting safety and care needs

Skilled Need / Skilled nursing facility — definition (24-hour skilled inpatient level)

DefinitionCare requiring the skills of licensed technical or professional personnel that must be performed or supervised by such personnel and provided as 24-hour inpatient skilled nursing care

Facility componentsIncludes physician, skilled nursing, dietary, pharmaceutical services and an activity program as a minimum

AvailabilityProvides continuous skilled nursing care on an extended basis (24-hour)

Background

Skilled nursing and rehabilitation involve interventions that must be performed or supervised by licensed clinical personnel to achieve medically desired results and ensure safety. Eligibility for skilled SNF or subacute care depends on the complexity, intensity, and frequency of treatments that cannot be provided safely at a lower level of care; examples include initiation or titration of medical therapies, management of actively healing wounds requiring aseptic technique, complex device care, or skilled rehabilitative programs with an active written treatment plan.

Discharge Criteria

There are no facility-level discharge criteria specified as required conditions for continuing SNF/subacute care in this policy. Discharge (or denial of continued stay) is appropriate when one or more of the not-medically-necessary conditions apply—for example, the member is ambulatory for household distances with less than minimal assistance and capable of ADLs with less than minimal assistance, the patient is not participating in the treatment plan, there is no practical improvement within a reasonable time, or skilled services are no longer needed.

Revision History

creationLatest

Policy established outlining L.A. Care clinical guidelines for skilled nursing facility and subacute level of care, defining admission, continued-stay, isolation, EBP, obesity, and sitter criteria.