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

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for continued skilled nursing facility stay. Findings:  The physician reviewer found that the enrollee has a history of Parkinsons disease and back pain. She was admitted to the hospital for difficulty walking due to severe back pain. She was transferred to a skilled nursing facility (SNF) due to acute-on-chronic back pain and spinal stenosis. She has been receiving physical therapy (PT) and occupational therapy (OT) for back pain and lack of sensation in her legs. A PT referral was made due to a new onset of compromised physical exertion level during activity and a decrease in functional mobility, strength, coordination, neuro motor control, balance, and postural alignment. She had functional limitations with ambulation, increased need for assistance, increased physical exertion during daily living tasks. PT was ordered daily, six days per week for 90 days to include gait training, therapeutic exercises, therapeutic activity, and neuromuscular re-education. OT was ordered daily, five days per week for 90 days to include self-care, therapeutic exercises, therapeutic activities, and neuromuscular re-education.  An OT progress note indicates the enrollee is performing lower body dressing at a contact guard level, toilet transfers at contact guard level and toileting with minimal assistance. A PT progress note indicates she is ambulating 50 feet with minimal assistance and a rolling walker, she is stand-by assistance for bed mobility, and she is minimal assistance for transfers.  An OT progress note indicates the enrollees functional level as minimal assistance for toileting and toilet transfers. According to the medical literature, justification for continued OT in an SNF includes maximization of independence with ADLs, development and instruction in a home exercise program, and increased functional activity tolerance.  Justification for continued physical therapy within an SNF is to increase independence with gait, enhance fall recovery abilities, and increase functional activity tolerance.  Guidelines for treatment planning of low back pain indicate skilled nursing facility care is necessary when the enrollee requires skilled nursing or skilled rehabilitation services, or both, on a 24-hour basis.  The medical record does not demonstrate the necessity for skilled 24 hour nursing care or physician medical management in a skilled nursing facility setting. Continuation of physical therapy and occupational therapy can be achieved in an outpatient setting to maximize functional independence in gait and ADLs.Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.