Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  C2-4 anterior spinal fusion; dysphagia; difficulty walking; general muscle weakness; and C3 corpectomy
 
Treatment:  Continued stay at the skilled nursing facility

The insurer denied coverage for continued stay at the skilled nursing facility.  The denial was reversed.

This patient is a female who was seen for a new admission assessment.  The patient's chief complaints/history and physical included a C2-4 anterior spinal fusion, deep vein thrombosis (DVT), dysphagia, difficulty walking, general muscle weakness, and C3 corpectomy.  The physical exam revealed the patient was comfortable with weakness noted to the extremities.  She was alert and oriented x2 and it was recommended that the patient received treatment to include physical and occupational therapy 5 to 6 days a week with supportive care.  The progress notes do detail that the patient was evaluated for long-term services at home previously and was awaiting determination in order to discharge.  The patient did need an at home caregiver to be safely discharged according to the note.  She did remain eager to return home.  She was seen by podiatry and by a general physician.  There were no new orders.  The patient continued treatment to include physical and occupational therapy.  Additional progress notes detailed that the patient coughed up whitish colored nodules with scant fresh blood.  It was recommended the patient undergo a biopsy of the tissue.  The patient did not have any complaints.  Additional documentation from a specified date detailed the patient required a Hoyer lift and sling for safe transfers out of bed as well as elevating leg rests for edema and a cushion to prevent skin breakdown.  The patient did have a slow limited return of use of her limbs and was recommended to utilize a hospital bed when discharged.

The patient was hospitalized and then required therapy six days a week, as well as assistance with transfers via Hoyer lifts due to weakness in her extremities.  A stay at a skilled nursing facility is recommended for patients who require skilled nursing or skilled rehabilitation services, or both, on a daily basis.  The clinical documentation submitted notes the need for physical therapy and occupational therapy with documentation of objective functional improvement towards set goals.  The services of this nature at this frequency could only be performed by a rehabilitation professional in an inpatient setting.  The weakness and difficulty with bed mobility would have made discharge home unsafe, since the patient was not independent with her activities of daily living (ADL's), and there was potential to improve her independence and safety.  A skilled facility was the best and safest option for a patient with rehab goal that is not independent enough to return home safely.  Therefore, the continued stay was medically necessary due to the patient's need for skilled therapy services and her inability to return home safely due to her hospital related medical condition.

The health plan did not act reasonably and with sound medical judgment or in the best interest of the patient.  

The carrier's denial of coverage for the continued stay at the skilled nursing facility is reversed.  The medical necessity is substantiated.