Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Skilled Nursing Facility. 

The insurer denied Skilled Nursing Facility Long Term Custodial Care. 
The denial is upheld. 

The patient is a male with a traumatic brain injury, subarachnoid hemorrhage, subdural hematoma, and pelvic fractures after being struck by a car with right lower extremity pain and weakness, and abnormal gait.  The medical records indicate that he has the following medical conditions: contractures. He was treated with physical and occupational therapy. He was minimum assistance for hygiene/grooming, toileting, and lower body dressing. He was standby assistance for upper body dressing. He was standby assistance for hygiene/grooming, contact guard for toileting, and minimum assistance for lower body dressing. He was standby assistance for upper body dressing.
He had no complaints. He was on a regular diet. He was alert, awake, and oriented. The neuromuscular exam was "negative" on physical exam. He was continent of urine. Extremity exam stated: "active range of motion (AROM) upper extremity (UE) & passive range of motion (PROM) to lower extremity (LE)." He was discharged from physical therapy (PT). An exercise program was recommended. He demonstrated the ability to stand on his own and requested a walker for ambulation. He was requiring less assistance with activities of daily living (ADL) tasks. The patient could participate in a home exercise program to include strengthening and range of motion exercises as well as home based or outpatient physical and/or occupational therapy. 
The health plan stated that "we decided we are not changing our decision to deny you Skilled Nursing Long Term Custodial Care." 
At issue is the medical necessity of Skilled Nursing Facility Long Term Custodial Care for this patient. 

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

The requested health service/treatment of Skilled Nursing Facility Long Term Custodial Care is not medically necessary for this patient. 

The patient had no complaints. He was on a regular diet. He was alert, awake, and oriented. The neuromuscular exam was "negative" on physical exam. He was continent of urine. Extremity exam stated: "AROM UE & PROM to LE". He was discharged from PT. An exercise program was recommended. He demonstrated the ability to stand on his own and requested a walker for ambulation. The patient could participate in a home exercise program to include strengthening and range of motion exercises as well as home based or outpatient physical and/or occupational therapy. Skilled Nursing Long Term Custodial Care is not medically necessary because he was minimal assistance sit to stand and minimum assistance with transfers. He was fair- with dynamic standing. He was able to ambulate 25 feet using a two wheeled walker with moderate assistance. He was standby assistance for hygiene/grooming, contact guard for toileting, and minimum assistance for lower body dressing. He was standby assistance for upper body dressing. The peer-reviewed medical literature in the United States at this time would not include Skilled Nursing Facility Long Term Custodial Care per the documentation. Further, the medical standard of care does not support Skilled Nursing Facility Long Term Custodial Care. 
Therefore, the requested health service/treatment of Skilled Nursing Facility Long Term Custodial Care is not medically necessary.