Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease, stroke, obesity, diabetes.
Treatment: Skilled Nursing Facility (SNF) (and ongoing physical and occupational therapy).

The insurer denied the Skilled Nursing Facility (SNF) (and ongoing physical and occupational therapy).  The denial is upheld. 

The patient has a history of coronary artery disease, tobacco use, obesity and diabetes.  She is reported to have had ischemic strokes in an unspecified time frame, with at least residual left leg weakness.  Post-stroke, she was reported to have been ambulating in a limited fashion.  She continued to smoke tobacco until she broke her left hip.

The patient underwent left hip surgery due to a fracture.  She was transferred to a subacute rehabilitation facility for further care.  She was diagnosed with a left leg deep venous thrombosis and was started on apixaban.  The patient was discharged from the subacute rehabilitation facility, having plateaued functionally.  She was not ambulating "much at all" following her hip fracture.  She returned home, where she lives with her spouse and son.  She was unable to transfer or ambulate at home.

The patient presented to an emergency room with worsening edema, left leg pain and inability to manage at home.  She was found to have acute deep venous thromboses in the left common femoral and popliteal veins, with possible clot instability.  She was started on heparin drip and transferred to a tertiary hospital for higher level care and vascular surgery consultation.  She was seen by vascular surgery who opined that her left leg deep venous thrombotic pathology was unchanged versus prior examination.  Vascular surgery advised that no surgical intervention was indicated as the risks of intervention were felt to outweigh the benefits.  Moving and ambulating were felt to not increase her risk of pulmonary embolism.  Heparin drip was discontinued, and she was resumed on apixaban.  

The patient was found to have hypomagnesemia, which was repleted.  She was found to have anemia, which was deemed chronic.  Her glycated hemoglobin (A1c) was noted to be 6.7.  Her blood pressure was well controlled without antihypertensive medications.

The patient was ambulating ten feet with a walker, requiring assistance to advance her left leg during swing.  She was transferring at the minimum assist level.  She was ambulating 40 feet with a walker, requiring assistance to advance her left leg during swing.  She had left foot drop and left knee genu recurvatum.

No, the proposed Skilled Nursing Facility (SNF) (and ongoing physical and occupational therapy) is not medically necessary.

The patient is reported to have had strokes in the past with residual left leg weakness.  She was a marginal ambulator prior to her hip fracture.  She has not been a functional ambulator since breaking her left hip, despite extensive subacute inpatient rehabilitation. She returned to the community when subacute inpatient rehabilitation was no longer covered by her health plan, but she was described as unable to manage at home despite the presence of her family.  She was rehospitalized within four to five days of returning home essentially for failure to thrive in the community, without evidence of any significant new medical pathology.  Her deep venous thrombotic disease was found to be unchanged.  During her current acute hospital stay, she has been participating with therapies with some modest ostensible gains, but she continues to require physical assistance to advance her left leg through swing phase.

Based on the clinical data, the patient is at her functional baseline of requiring physical assistance for all basic mobility.  There is no reasonable expectation of clinically meaningful functional improvement with further inpatient rehabilitation at this time as she remains unable to advance her left leg on her own, and she has otherwise functionally plateaued.  She has a poor prognosis with respect to functional and health outcomes given the burden of her multiple underlying conditions, but the proposed return to a subacute inpatient rehabilitation facility level of care is not expected to meaningfully impact this in a favorable direction.  Based on the available documentation, the patient is at a custodial level of care, which can be provided in the community.

The patient has plateaued functionally and is not a candidate for further rehabilitation at an inpatient setting.  She is at a custodial level of care.