Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System. 
Treatment: Skilled Nursing Facility. 

The insurer denied Sub-Acute Rehabilitation in a Skilled Nursing Facility (SNF)-for a total of 7 days. The denial was upheld. 

The patient is a female with tracheostomy stoma malfunction. She has a history of coronavirus (COVID) with respiratory failure, tracheal stenosis, and subglottic stenosis. She was receiving home care services prior to her admission to the hospital and nursing home. The medical records provided indicated that the patient was walking 30 feet using a rolling walker while in the hospital and requiring minimal assistance with bed mobility while in the hospital. She was admitted to the Skilled Nursing Facility due to the need for nursing care with physical therapy (PT), occupational therapy (OT), and Speech Language Pathologist (SLP) five days per week. 
She was admitted to the Skilled Nursing Facility due to the need for nursing care with PT, OT, and SLP five days per week. OT notes indicated that she was maximum assistance for toileting, bathing, lower body dressing and moderate assistance with upper body dressing. She required minimum assistance with hygiene and grooming. She had a tracheotomy and a feeding tube. She continued on a tracheotomy (trach) collar with no acute distress. Pulmonary, stated that she had a history of COVID with respiratory failure, tracheal stenosis, and subglottic stenosis. She was alert and comfortable on a trach collar. Her oxygen (O2) saturation was 98%. Respiratory rate was 18. Treatment included trach care, tracheal suctioning, inhaled bronchodilators, and supplemental oxygen at 2 liters per minute. 

At issue is the medical necessity of Sub-Acute Rehabilitation in a Skilled Nursing Facility (SNF)-for a total of 7 days. 

The health plan's determination of medical necessity is upheld in whole. 

The requested health service/treatment of Sub-Acute Rehabilitation in a Skilled Nursing Facility (SNF)-for a total of 7 days is not medically necessary for this patient. 
The patient is a female with tracheostomy stoma malfunction. Pulmonary, stated that the patient had a history of COVID with respiratory failure, tracheal stenosis, and subglottic stenosis. She was alert and comfortable on a trach collar. Her O2 saturation was 98%. Respiratory rate was 18. 
The PT note stated that lower extremity strength was 2-/5. Lower extremity range of motion was normal. She was maximum assistance for bed mobility and total dependence for transfers, gait, wheelchair mobility, stairs, and community mobility. She was maximum assistance with transfers, ambulated 15 feet with maximum assistance, and moderate assistance with bed mobility. Bilateral upper extremity strength was 3-/5. She was maximum assistance for lower body dressing. During the time frame from hospital discharge, there was no documentation of significant improvement in toileting, bathing, dressing, transfers, ambulation, wheelchair mobility, bed mobility, or strength. Therefore, the requested health service/treatment of Sub-Acute Rehabilitation in a Skilled Nursing Facility (SNF)-for a total of 7 days is therefore not medically necessary for this patient. 

Sub-Acute Rehabilitation in a Skilled Nursing Facility (SNF)-for a total of 7 days is not supported by the peer-reviewed medical literature in the United States at this time. The medical standard of care does not support the requested health service/treatment of Sub-Acute Rehabilitation in a Skilled Nursing Facility. The patient had a lack of progress in PT, OT, and SLP. 

Therefore, the requested health service/treatment of Sub-Acute Rehabilitation in a Skilled Nursing Facility (SNF)-for a total of 7 days is not medically necessary.