Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility level of care and authorization and coverage for 60 days of assisted living care services after the enrollee has been discharged from skilled nursing facility for treatment of the enrollee who has a recent history of multiple fractures, respiratory failure and hypoxia. Findings:  The physician reviewer found that The patient sustained multiple major soft tissue, respiratory system and orthopedic injuries due to a motor vehicle accident in late October 2017.  The patient had a prolonged and complicated course in the critical care setting, undergoing multiple surgeries.  The patient was medically stabilized by mid November 2017 and transferred to a skilled nursing facility at that time. The patients weight bearing status and activity restrictions have been gradually liberalized. The patient was only allowed full weight bearing status in the bilateral lower limbs on 12/20/17.  Prior to that, she was touch down weight bearing in the right lower limb and weight bearing as tolerated in the left lower limb.  The patient continues to have left knee instability due to ligamentous injury and requires use of a long leg brace.  The patient had a right frozen shoulder on orthopedic examination on 12/20/17, a sequelae of a fracture dislocation, extensive axillary soft tissue injury and prolonged disuse, requiring intensive intervention.  The patient continued to have significant self-care limitations, albeit with significant potential for recovery with appropriate rehabilitation interventions. The patient continued to have an open wound in the left chest requiring daily packing. As of 12/25/17, there were ongoing skilled therapy needs necessitating skilled nursing facility level care for optimal outcomes. The patient continued to make functional progress with her upper and lower body self-care as indicated by her functional status on the 1/8/18 note.  Ongoing care at the skilled nursing facility from 12/25/17 and ongoing was and is appropriate and medically necessary. She is at high risk for complications such as arthrofibrosis and permanent contracture development on account of her injuries and requires aggressive mobilization. Further care subsequent to 1/8/18 should be re-evaluated every one to two weeks for progress and fitness for community discharge or functional plateau. Accordingly, the skilled nursing facility level of care from 12/25/17 forward were and are medically necessary for the treatment of this patients medical condition. However, 60 days of assisted living care services after the patient has been discharged from skilled nursing facility is not medically necessary for treatment of this patient. Assisted living care after skilled nursing facility level care is a custodial service and would not be indicated for treatment of this patient. Final Result: The reviewer determined that a portion of the services at issue was and is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.