Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Peripheral vascular disease, coronary artery disease, congestive heart failure, diabetes
Treatment: Continued Custodial Care (Long Term Care)
The insurer denied the continued custodial care (long-term care).
The denial is overturned. 

The records report that the patient is a male with a history of multiple chronic health issues, including peripheral vascular disease, coronary artery disease, cardiomyopathy, congestive heart failure, hypertension, hyperlipidemia and diabetes.  He has undergone multiple vascular interventions for his lower limbs.  Earlier in the year, computed tomography (CT) angiogram showed occluded right external iliac and femoral arteries, and a patent right internal iliac artery.

Approximately a month later, the patient underwent a right transfemoral guillotine amputation.  His postoperative course was complicated by a persistently infected residual limb.  He underwent multiple debridements/washouts of the residual limb.  Imaging showed bilateral aortoiliac stent and a right femoral artery stent, with a possibly occluded femoral vessel.  He was deemed to require a right hip disarticulation but this was not pursued.  He was medically stabilized with further antibiotics and debridements.  A vacuum-assisted closure dressing was ultimately placed on the residual limb wound.  His pain management regimen was adjusted.  There were ongoing non-weightbearing restrictions for the right lower limb.

A month later, the patient was transferred to a skilled nursing facility for further care.  He was noted to live with family at baseline.  On therapy assessments, he was requiring maximum assistance for transfers.  He was non ambulatory.  He was dependent for bathing, toileting and lower body dressing.  He had persistent pain.  He participated in therapies and made progress.

Approximately two months later, the patient was requiring contact guard assistance for transfers and lower body dressing.  He was requiring minimum assistance for lower body bathing.  He continued to have a vacuum-assisted closure dressing on the right lower residual limb.  He remained on linezolid antibiotics.

Yes, the proposed treatment, continued custodial care (long-term care) was medically necessary.

The records indicate that the patient had a persistently non-healing right lower limb wound.  He had undergone multiple debridements and washouts of his residual limb following a right transfemoral amputation, but he had suboptimal proximal arterial circulation.  He was reportedly in need of a hip disarticulation.  He remained on antibiotics and a vacuum-assisted closure dressing.  He was non-ambulatory and continued to require assistance for basic self-care and mobility.  He required ongoing custodial/long-term care until his medical needs could be more definitively addressed.  He was not appropriate for discharge to the community.

The patient had a significant, persistent wound in his right lower limb following a guillotine transfemoral amputation that remained non-healing due to persistent infection and dysvascular status.  He continued to require custodial level assistance for his basic self-care and mobility.  He was at high risk for catastrophic medical complications without ongoing custodial level assistance, including but not limited to further wound deterioration, pressure injury development, sepsis and death.