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What is the actual definition of “medically necessary”?

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Qualification for SNF paid for by Medicaid is both by financial necessity and 'Medically at Need".

Medicaid doesn't generally accept a doctor all of a sudden saying a patient is in medical need of SNF. There has to be a fat folder of documentation.

If dad has been in the hospital and then rehab, the documentation is there. If he's at home, you need to alert the doc that you need to build a case for medicaid to consider him "medically at need".
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Reply to BarbBrooklyn
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A problem could be the nurse getting him to take the extra prn dose when he is in a quickly escalating event, plus he will have a roommate in a SNF, your dad won’t have a private room unfortunately. His physicians have to give the SNF a clear picture of dad’s behavior as if he doesn’t ethically or medically it could be a liability for the doctor.
Maybe ask his PCP to admit him to a psych hospital for evaluation and medication therapy to see if your dad can be medicated daily to keep his impulsive behavior in check.
Maybe get your local Department of Aging involved to ask about community resources or if they may be familiar with any other situations like his?
This is so hard for you and your father. Do his doctors have any ideas?
It still will be a safety issue for a SNF & if any of them do admit him and he acts out, they will call 911 & have your father sent for psychiatric evaluation if that happened. 
I am not sure you can force his insurance company to pay for a SNF stay with no doctor’s order. Sounds like he doesn’t qualify for admission to a medical hospital facility anyway, yet alone be there for the three days. It’s rare that SNF takes patients directly from home as usually the patient comes from an “acute” hospital setting with clear medical needs.
There has to be some sort of solution but I don’t have one. Won’t Medi-cal pay for in home care in some instances? Maybe the dept of aging knows more about this? I live on the east coast & not familiar with California.
This is very complicated, so sorry for you!
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Reply to Shane1124
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Of course we follow the doctor’s orders and he is on an as-needed prescription. I am not looking for advice i can ask his dr about... i am asking about people’s experience with SNF going by “medically necessary” or if insurance would refuse to pay if they do not consider no physical ailments and NOT being “medically necessary”. My dad has a primary physician and a neurologist... so i am not asking about his medicine. All i was saying was that a nurse should determine if he needs more (since it is as-needed) rather than just any caregiver... which would justify a SNF and Insurance should deem it necessary.
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Reply to Lookin4hlp
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I'm confused by your Seroquel question. Who prescribed it? Is he on a scheduled dose or is it PRN ( as needed). Have you spoken to the prescribing doctor about his agitation and destructiveness?

You talk about a nurse being able to give him more seroquel if necessary. That's only true if a doctor has written the prescription that way. What dosage is he on?
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Reply to BarbBrooklyn
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These are questions about medication that you might want to discuss with his doctor. Has he seen a geriatric psychiatrist or neurologist?
Have you spoken with Area Agency on Aging? Asked them to do a needs assessment?
About medical need. I would assume each organization has criteria that allows them to accept or deny coverage or acceptance.
Would a memory care accept him for a respite stay? That would give a real opportunity to try him in memory care. Or an involuntary 72 hr hold in a psychiatric facility might allow for a med adjustment to help him settle down and help with the hallucinations? If he is a danger to himself or others you can ask the courts to sign an order for him to be evaluated. Call the Area Agency on Aging and see what they have to suggest. I’m sorry if that’s already been suggested and done. I haven’t read all your previous posts.
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Reply to 97yroldmom
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Hi. No my dad is not really aggressive... he gets agitated and doesn’t stop complaining about the people in the house “hitting” him. He combats his unpleasant hallucinations by leaving the house... where lies a major issue. When i mentioned restraints i meant medicinal not physical. I mean there are times he needs a little extra Seroquel. The only time he almost got physical was one episode during a Klonopin withdrawal but hasn’t done that since. I am just hoping a SNF will accept him straight from home through Blue Shield. Blue will pay a certain number of days then medicare kicks in and then MediCal takes over - hopefully. Problem is that he isnt bedridden in fact he can walk pretty fast... like a roadrunner :)
This is so complicated! How much Seroquel do some of you administer? I am curious if my dad takes too little...
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Reply to Lookin4hlp
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“ Medically Necessary” is of course a huge factor for admission to a SNF but facilities need to evaluate the patient’s past behavior so assure the safety of their other patients.
I can’t remember for sure but are you the person who stated that your dad’s doctor report stated he was aggressive? SNF have to take that under consideration in providing a safe environment for their other residents.
Was it you who also stated a nurse can use restraints and medication to control those aggressive behaviors? Nurses will not do that as it is against the law.
Yours is a hard position to be in& I sense your frustration.
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Reply to Shane1124
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So it sounds like it could apply to a lewy body dementia and Parkinsons patient with no physical ailments 🤔 so medi-cal would accept him and pay for a SNF
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Reply to Lookin4hlp
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From the web

health service or treatment that is mandatory to protect and enhance the health status of a patient, and could adversely affect the patient’s condition if omitted, in accordance with accepted standards of medical practice.

When applied to hospitalisation, medically necessary means that a plan member’s acute care needs are such that he or she cannot receive safe and adequate care as an outpatient or at a lower level of care.

Medically necessary, criteria
A. Appropriate for the symptoms and diagnosis or treatment of a condition, illness or injury.
B. Provides for the diagnosis or direct care and treatment of the condition, illness or injury.
C. In accordance with the standards of good medical practice in the service area.
D. Not primarily for the convenience of a plan member or a plan provider.
E. The most appropriate level or type of service or supply that can safely be provided to the plan member.
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Reply to 97yroldmom
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Prescribed or verified by the doctor.
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Reply to gladimhere
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