Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p (status post) Fall
Treatment: Continued Stay At Subacute Rehabilitation Facility 
The insurer denied the Continued Stay At Subacute Rehabilitation Facility 
The denial is upheld. 

The records report that the patient is a male with a history of multiple sclerosis.  His baseline is living alone in the community in a house with five steps to enter, then a flight to the bedroom.  He used a walker at baseline.  Other medical history includes hypertension and a bladder mass.

The patient was admitted to a hospital after a fall.  He was diagnosed with rhabdomyolysis and a urinary tract infection.  He was treated and medically stabilized.

The patient was transferred to a skilled nursing facility for further care.  On therapy evaluations, he was dependent for transfers.  He was non ambulatory.  He required max assist for manual wheelchair mobility.  He was supervision to contact guard assist for eating and oral hygiene.  He was dependent for oiling, bathing, toileting and dressing.  Speech therapy recommended a mechanical soft/ground textures oral diet with thin liquids.  He participated in a multidisciplinary rehabilitation program.  Nursing noted some periods of confusion.

Approximately 10 days later, the patient completed his antibiotic course for his urinary tract infection.

Aprroximately four days later, the patient was transferring at max assist.  He was ambulating 15 feet with a walker at max assist.

One day later, the patient was requiring max assist for upper and lower body dressing.

Approximately five days later, a physician's follow up note indicated that the patient had low back pain and right foot paresthesia.  Examination noted normal strength in the upper limbs and fair to good strength in the lower limbs.  There was clonus at the left ankle.  A lidocaine patch and gabapentin trial were recommended.

Approximately six days later, a physician's follow up note indicated that the patient had continued low back pain.  The frequency of Percocet analgesia was increased.  Baclofen was continued.

Approximately two days later,  the patient was transferring at max assist.  He was ambulating 20 feet with a walker at mod assist.  He had poor balance and was unable to negotiate turns.  He was requiring mod assist for upper body dressing.  He was requiring max assist for lower body dressing.  He was requiring max assist for bathing.

The followind day, a physician's follow up note indicated that the patient had controlled low back pain.

Approximately four days later, the patient was requiring mod assist for upper body dressing.  He was requiring max assist for lower body dressing.  He was requiring max assist for bathing.

Approximately eight days later, a  physician's follow up note indicated that the paresthesia had resolved.  The patient's back pain had improved.

Approximately two days later, the patient was transferring at max assist.  He was ambulating 20 feet with a walker at mod assist.  The physician noted "lack of judgment."  It was noted that he was awaiting a steroid infusion, either at the neurologist's office or at the skilled nursing facility.

Approximately four days later, the patient was requiring supervision for upper body dressing.  He was requiring max assist for lower body dressing.  He was requiring max assist for bathing.

Approximately three days later,  it was noted that the patient was awaiting an ocrelizumab (Ocrevus) infusion.

No, the Continued Stay At Subacute Rehabilitation Facility was not medically necessary.
The patient had plateaued functionally at a level where he was going to be requiring extensive physical assistance for all basic mobility and most self-care.  He did not improve beyond transferring at essentially a maximal level of assist.  He was not improving to functional ambulation.  For instance, he lacked the balance to make turns.  He also had cognitive impairments with impaired judgment, for which he was going to be requiring substantial levels, if not constant levels, of supervision for safety.  There were no indications of any progress with respect to arrangements to assist the patient with a safe reintegration back to the community in terms of both his physical and cognitive/safety needs.  The patient was at a custodial level of care.  The care in question was not medically necessary.