Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/circulatory-atrial fibrillation. 
Treatment: Skilled Nursing Facility. 

The insurer denied continued admission to Center for Rehabilitation and nursing. 
The denial is overturned. 

The patient is a male admitted to skilled nursing facility following hospital course significant for atrial fibrillation (AFIB) with rapid ventricular response (RVR), thrombocytopenia, acute respiratory failure with hypoxia, alcohol abuse/withdrawal, transaminitis secondary to alcohol use and hyponatremia thought to be related to alcohol use. 

The subject under review is the medical necessity for the requested Continued Admission to Center for Rehabilitation and Nursing. 

The requested service of continued skilled nursing stay was medically necessary and appropriate for this patient. This patient was hospitalized for AFIB with RVR complicated by alcohol abuse that began after losing his job. Ataxia was a limiting factor and while therapy did succeed in improving the patient's balance it took time. During this time, he was medically managed for uncontrolled back pain. Additionally, he received regular lab work for monitor for electrolyte deficiencies. For example, he required increase in potassium chloride (KCL) supplementation. He continued to make progress with therapy, and this allowed him to ready for a safe discharge. 

The patient was admitted to skilled nursing facility following hospital stay related to AFIB with RVR, thrombocytopenia, acute respiratory failure with hypoxia, alcohol abuse/withdrawal, transaminitis secondary to alcohol use and hyponatremia. While in skilled rehab he had low back pain treated with both oral pain medication and a sacroiliac steroid injection. With therapy, he progressed in a reasonable fashion.  Therapy noted that patient was contact guard assist (CGA) for bathing (from minimal assist [MINA] since admission), CGA for toileting (from MINA since admission), CGA for lower body dressing (from MINA on admission). He had also progressed to close supervision (from MINA) with stand pivot transfers and was ambulating 400'(feet) with wheeled walker (WW) and wheelchair follow (noted poor endurance) at supervision level. He was making progress but still not at a safe level for discharge (history of alcohol abuse combined with secondary neuropathy felt to be causing ataxia). Also, at this time he was unable to complete steps (with documentation noting that he had 3 steps to enter his home). Therapy continued, though, and eventually he was able to ascend/descend 10 steps with 2 rails and CGA. He was also independent with stand pivot transfers and ambulating with a WW (with no supervision or wheelchair follow noted). Subsequently he was able to ascend/descend steps with 2 railings and supervision and was ambulating without and assistive device. At this point, this reviewer opines that he was safe and ready for discharge. Discharge plan had been ongoing, as therapy noted that patient "lives with dad in single story home with laundry in the basement. Three steps to enter with railing on one side." Additionally, the medical progress note stated that therapy was recommending an additional 2-3 weeks of therapy. Therefore, discharge was being discussed and appropriately planned for.