Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple aneurysms
Treatment: Continued skilled nursing facility stay
The insurer denied the Continued skilled nursing facility stay.
The denial is upheld. 

The patient is a female. The patient is a retired nurse with a history of multiple aneurysms.  Her baseline was living in the community with her husband at an independent level.

The patient underwent an elective clipping of a left internal carotid artery terminus aneurysm, which was complicated by a left choroidal infarct.  There was residual right-sided (dominant side) weakness, right-sided neglect and transcortical motor aphasia.  There was also cognitive decline, likely due to medication effects (Vimpat and Decadron).

The patient was transferred to an acute rehabilitation hospital/facility for further care.  Her medications were adjusted.  She recovered from a urinary retention condition.

The patient was admitted to a skilled nursing facility for further care.  Admission diagnoses included post-stroke reactive depression, vascular dementia and hypertension.  She was on a regular consistency oral diet.  She received rehabilitation services (including physical, occupational and speech therapies) for approximately two months.

It was noted that the patient could be transitioned to a lower level of care if she had 24/7 care and a neurorehabilitation program in place.  There were noted to be agency staffing and/or other logistical issues (including due to the COVID-19 pandemic) complicating the arrangement of home health aide services, home therapy services, and outpatient rehabilitation services.

It was noted that the patient was continue with further care at the same skilled nursing facility "under [a] new payer source."  She had mild to moderate receptive aphasia, marked expressive aphasia, right visual field cut, and right hemiparesis.  Yes-and-no accuracy with respect to more complex questions was variably accurate.  She was stand by assist for bed mobility.  She was contact guard assist for transfers due to unsteadiness.  She was ambulating 175 feet with a walker at contact guard assist due to unsteadiness.  The discharge plan was home with home health services.

It was noted that the patient's husband was working full time and was not going to be available to assist at all times.

The patient had stable cardiovascular hemodynamics without pharmacotherapy.  She had a good mood.  She was transitioned to a "lower level of care," due to an unavailability of local home health care services where she was residing.  The patient received appointments for outpatient rehabilitation services to start.  She was to see neurosurgery to determine when she would undergo a follow up MRI (magnetic resonance image) study.

No, the Continued skilled nursing facility stay was not medically necessary.

The records indicate that the patient had persistent and generally stable deficits following her stroke.  She continued to have right hemiparesis, communicative issues, cognitive deficits and safety deficits.  She was otherwise medically stable and mobilizing at a household level, requiring cues, supervision and intermittent minimal levels of physical assistance due to safety and unsteadiness/control issues, including scissoring of her right leg during ambulation. A couple of months later, she was capable of transitioning to a less intensive rehabilitation setting of care (e.g., community-based rehabilitation) and did not require ongoing skilled nursing facility level care for her stroke rehabilitation.  Notably, a statement to that effect had already been made by the facility's staff.