Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke, hypertension, hyperlipidemia, diabetes mellitus, end stage renal disease, anemia, recurrent urinary tract infections, bilateral lower limb diabetic neuropathy, and debility.
Treatment: Continued Stay in a Skilled Nursing Facility, Level 1
The insurer denied: Continued Stay in a Skilled Nursing Facility, 
Level 1
The denial is upheld.

The records indicate that the patient is an adult female with a history that includes old stroke, hypertension, hyperlipidemia, diabetes mellitus, end stage renal disease (on chronic hemodialysis), anemia, recurrent urinary tract infections, bilateral lower limb diabetic neuropathy, and debility. Her baseline is living alone in an elevator-accessible apartment. She uses a walker to ambulate. She has home care services 4 hours a day, 7 days a week. She owns a manual wheelchair at home. The patient is reported to have fallen 6 months ago at dialysis, sustaining trauma to the left knee. She was admitted to the hospital 5 months ago with worsening left knee pain with effusion. Arthrocentesis did not show evidence of a septic joint. She was transferred to a skilled nursing facility at that time. She was re-hospitalized later that month, with bacteremia related to a urinary tract infection, as well as metabolic encephalopathy. She was placed on long-term antibiotics (ceftolozane-tazobactam). A left arm arteriovenous fistula was placed 4 months ago. She was transferred back to the skilled nursing facility at some point.
Three months ago, the patient was re-hospitalized from the facility with a swollen and painful left knee with a history of trauma to that knee about three months earlier, with worsening symptoms over the prior three days at the facility. She was diagnosed with a septic left knee. Her mental status was reported to be at baseline. There were no focal neurological deficits. Hemoglobin was 7.3. Intravenous vancomycin was added to the ceftolozane-tazobactam. She underwent left knee surgical incision and drainage with washout 3 months ago. She was noted to be anemic (with a hemoglobin of 5.9) and was transfused 1 unit of packed red blood cells. Two days later, the patient's hemoglobin was 8.1. Therapy noted that she was moderate assist for transfers and moderate assist for ambulating 4 steps with a walker. She was noted to have an antalgic gait. Subacute rehabilitation was recommended. Three days later, the patient was transferred back to the skilled nursing facility. She was to be on intravenous vancomycin and ceftolozane-tazobactam. She was tolerating an oral diet. She tolerated her antibiotics. She underwent hemodialysis. Anemia was stable and 
further to be addressed by renal. She received routine skin care. She participated in therapies. The disposition plan was returning home with increased home services. Functionally, as of 2 months ago, the patient was maximum assist for bathing and toileting. She was dependent for lower body dressing. The patient was maximum assist for transfers. She was ambulating 10 feet with a 
walker at maximum assist. The patient was maximum assist for transfers. She was ambulating 15 feet with a walker at maximum assist. She was maximum assist for bathing and toileting. She was dependent for lower body dressing. As of last month, the patient was moderate assist for transfers. She was ambulating an unspecified distance at moderate assist. The patient was maximum assist for bathing and toileting. She was dependent for 
lower body dressing. The health plan denied coverage of skilled nursing facility level care. This denial is being appealed.

The Continued Stay in a Skilled Nursing Facility, Level 1 was not medically necessary.

The patient had undergone extensive rehabilitation. She had plateaued functionally at a level where she was only ambulating very short distances with significant physical assistance needed, 
with only a marginal improvement since her functional status in the acute hospital most recently. She was still requiring maximum to total assist for lower body self-care, with no significant 
improvement. Given her underlying conditions, her long-standing debility at baseline, and her course to date, she was not reasonably expected to make any clinically significant functional gains with more rehabilitation. She did not have any ongoing skilled nursing or medical issues requiring ongoing facility level care. She was at a custodial level of care. The ongoing skilled 
nursing facility level care in question was not medically necessary.