Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal 
Treatment: Skilled Nursing Facility 
The insurer denied skilled nursing facility for medical necessity. The denial was overturned in whole. 

The patient is a female with a past medical history of hypertension, aortic stenosis, status post transcatheter aortic valve replacement (TAVR), traumatic intracranial hemorrhage and subarachnoid hemorrhage requiring right hemicraniectomy for decompensation with subsequent ventriculoperitoneal (VP) shunt prior to intracranial abscess evacuation, baseline since then bedbound and nonverbal. She had presented to the emergency room with altered mental status and cloudy urine. She had been treated for a urinary tract infection (UTI) by a community provider. 

The patient was admitted to the hospital and treated with intravenous (IV) antibiotics, seen by neurosurgery due to shunt malfunction resulting in toxic metabolic encephalopathy, and evaluated by physical therapy and speech therapy during her hospital stay. The patient was on tube feeds, 5 cans/day with a trial of pureed foods. The patient had a Foley catheter. Outpatient genitourinary (GU) follow-up was recommended. Subacute rehab was recommended by the patient's provider and ancillary care team. 

Physical therapy stated the patient rolls and scoots with maximal assistance. The patient is total assistance with turning in bed without bed rails, lying on back to sitting on edge of flat bed, moving to and from a bed to chair, standing up from chair, and walking in hospital room, climbing 3-5 steps with a railing. 

The physician provided notes stating the patient's medical diagnoses during hospitalization and recommendation for subacute rehab, but noted denial from the health plan. 

The insurer sent a final adverse determination letter stating they were upholding all or part of the initial denial. The denial letter further stated the records showed that the patient could complete daily tasks as well as she could before she was in the hospital and records did not show that the patient needed daily skilled therapy, daily nursing care, and recommended care at home with home care or a long-term care facility. The patient's provider appealed the denial decision. 

At issue is the medical necessity of the Skilled Nursing Facility. 

The health plan's determination is overturned in whole. 

The requested health service/treatment of Skilled Nursing Facility is medically necessary for this patient. 

The patient had a change in her baseline mental status, requiring hospitalization and treatment for urinary tract infection as well as shunt malfunction. The patient was receiving tube feeds, but was recommended for trial of oral intake of pureed foods and snacks. The patient had a Foley catheter. According to physical therapy notes the patient was able to answer yes and no questions by nodding her head, was able to perform active range of motion (AROM) of right lower extremity and right upper extremity, and had goals set for bed mobility, transfer training, therapeutic activities, therapeutic exercise, and neuromuscular reeducation. The patient was hospitalized with a hospital-related medical condition and the patient's doctor decided the patient needed daily skilled care including physical therapy, speech therapy, social services, and nursing care. Although the patient had debility prior to admission to the hospital, she had worsening of functional capabilities not allowing her to return home. Physical therapy and her physician provided her with a plan for skilled nursing services in a rehabilitation setting, with a goal to return home at prior level of functioning by transferring from the hospital to subacute rehab. In summary, the skilled nursing facility for this patient is medically necessary.