Falk ex rel. Samolyk v. Chater

No. 2:92cv807 (AHN) (D. Conn. Oct. 27, 1995). ; Clearinghouse Number: 50932

Description

Claimant Entitled to Medicare Coverage for Post-Hospital Skilled Nursing Facility Care

Abstract

Adopting the magistrate’s recommendation, the district court has held that plaintiff, an 82-year-old woman admitted to a nursing facility following a 95-day hospitalization, is entitled to Medicare coverage for skilled nursing facility care. Upon admission, plaintiff was diagnosed with a fourth-degree pressure sore, hyponatremia, paraplegia, proteus mirabilis sepsis (a bacterial infection), atonic bladder with chronic indwelling catheter, congestive heart failure, and senile dementia. At the facility, she received daily injections of vitamin B-12 and various oral medications, her indwelling catheter was irrigated daily and replaced monthly, she was treated for decubitus ulcers and recurrent fevers, and she received physical therapy. Finding that plaintiff did not require or receive a skilled nursing facility level of care, the administrative law judge (ALJ) denied Medicare coverage for her 120-day stay at the facility. On appeal, the magistrate found that plaintiff had received skilled care in the form of assessment of urine, monitoring for and treatment of urinary tract infection, irrigation and replacement of catheters, assessment of the effects of medication and of skin integrity, and treatment of decubitus ulcers. Considered in conjunction with her other medical problems, including paraplegia, senile dementia, malnutrition, and inability to leave her bed without the use of a hydraulic lift, the record demonstrated that plaintiff required and received a skilled level of care during the period in question. Counsel notes that, while the ALJ based his decision largely on plaintiff’s doctor’s intermediate care facility certification, the magistrate found that the Social Security Act does not distinguish between skilled nursing facility and intermediate care facility levels of care for determining Medicare coverage.

Additional Information

Attorney Information
Plaintiff represented by Edward Dale, Legal Assistance to Medicare Patients, 872 Main St., P.O. Box 258, Willimantic, CT 06226, (203) 423-7560.
Docket Date
1995-10-27 00:00:00+00:00