Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Foot ulcer, right foot.
Treatment: Long term custodial care.
The insurer denied the long term custodial care. 
The denial is upheld.

This patient is an adult male with a history that includes atrial fibrillation/flutter,
hypertension, hypercholesterolemia, tobacco use, marijuana use, diabetes and a
chronic right lateral plantar foot ulcer. He was living with his sister in the community
at an independent level, ambulating with a cane/crutches and a controlled ankle
motion boot. His residence in the community has multiple steps to walk up in order
to enter.

The patient was hospitalized with a worsening of his chronic right foot ulcer. Work up revealed osteomyelitis. He was treated with intravenous antibiotics and underwent an incision and drainage of a right foot abscess. He became septic and received critical care in the intensive care unit. He underwent a delayed primary closure. He had non-weight-bearing restrictions for the right foot.

The patient was transferred to a skilled nursing facility for continued
medical and rehabilitation care. He was noted to have amputations of the 5th toes
on each foot. The date of these amputations were not documented, but there was
no indication that these amputations were recent. His toenails were noted to be
elongated, dystrophic and mycotic-appearing. There was a history of acute renal
failure. His vitals were stable. He denied pain. He was on an oral diet. He was not
on supplemental oxygen. He was continent of bladder and bowels. He was to
complete five weeks of Zosyn intravenous antibiotic therapy, which was to be
administered through a line in his proximal left upper limb.

On therapy evaluations, the patient was requiring minimal assistance for
transferring. He was standing for 30 seconds with bilateral crutches at minimal
assistance. He was ambulating five feet with bilateral crutches at moderate
assistance with two aides and with a wheelchair following.

The health plan has denied coverage of the facility's care as it was deemed that the patient's needs could be met in a community setting and that permanent long-term care is not medically necessary.

No, the Long Term Custodial Care is not medically necessary.

Standard of care for sepsis includes intravenous antibiotics in an acute hospital
setting, other critical care services as warranted, and rehabilitation services if
warranted (Prescott HC and Angus DC).

Standard treatment for diabetic foot ulcers typically includes optimization of diabetic
control, local wound care (e.g., topical agents, dressings, and debridement if
needed), antibiotics if indicated, and restricting weight bearing and/or activity as
needed (Bader MS and Brooks A,; Uckay I, et al.; Nikoloudi M, et al.). With an adequate blood supply and appropriate supportive measures, these
ulcers should generally heal.

That being said, in this patient's case, the patient was medically stabilized in the
acute hospital following sepsis due to a worsening diabetic foot ulcer with
osteomyelitis. He was started on intravenous antibiotics. He underwent drainage
of an abscess and delayed primary wound closure. He received critical care
services while acutely septic. He was then transferred to a skilled nursing facility to
complete his intravenous antibiotics and for rehabilitation. He completed his
intravenous antibiotics. He was subsequently placed on oral
antibiotics. He has undergone further wound care. Despite continued non-weightbearing restrictions, he progressed with therapies and was at an independent to
supervision level for his household mobility using crutches, including on stairs.
There were no indications that his care could not have been transitioned to the
community. He had a domicile to return to. He
could have received nursing and further therapy care in the community. He could
have received his medical care as an outpatient. Care in a facility was not medically necessary.