Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lymphedema, diabetes, chronic kidney disease. 
Treatment: Continued Skilled Nursing and Rehabilitation Services. 

The insurer denied the Continued Skilled Nursing and Rehabilitation Services. 
The denial is upheld. 

The patient is a female with general debility. Relevant medical history includes type 2 diabetes mellitus, morbid obesity, lymphedema, pseudo motor cerebri, chronic kidney disease, hyperlipidemia, hypothyroidism, and hypertension. 

Prior to admission, the patient lived alone in an apartment with three steps to enter and was independent. However, it is noted that when pre-certification was completed she was living with her husband. 

A progress note indicates that a discharge meeting was held. With regard to physical therapy, the patient was noted to be independent with bed mobility and transfer and walking up to 150 feet with a walker. From an occupational therapy standpoint, the patient was independent with self care tasks. The patient had some capability concerns, but durable medical equipment is documented to have been ordered. 

Contact notes include a clinical update in which it is noted that the patient was ambulating 100-120 feet independently and was independent with upper body dressing/bathing, lower body dressing/bathing, toileting, transfers, bed mobility, and other activities of daily living (ADLs). 

A letter from the patient explaining the reason for a continued stay was reviewed and does not add new information to change the decision. 

No, the requested continued inpatient skilled nursing and rehabilitation admission is not medically necessary. 

The plan has appropriately denied coverage for continued admission to a skilled nursing facility (SNF) because it was not medically necessary. The patient did not meet all criteria for skilled nursing facility (SNF) care according to InterQual Criteria for Skilled Nursing Facility (SNF) Admission because she was ambulating 100-120 feet independently and was independent with upper body dressing/bathing, lower body dressing/bathing, toileting, transfers, bed mobility, and other activities of daily living (ADLs). 

The patient did not meet the InterQual requirements as she had no ongoing clinical issues and was independent with most activities of daily living (ADLs). Her continued stay in the skilled nursing facility (SNF) was custodial in nature. Treatment for lymphedema can be done on an outpatient basis and does not require skilled nursing facility (SNF) admission. Documentation from the occupational therapist includes recommendation for lymphedema treatment five times per week. Treatment of this frequency could be carried out concurrently for a patient who requires a skilled nursing facility (SNF) stay for medical reasons, but because lymphedema requires long-term treatment and it can be done at a lesser level of care, this treatment alone does not substantiate medical necessity for an ongoing stay. The patient may also not require this frequency of treatment once therapy is established on an outpatient basis for which there is documentation that there were clinics accepting new patients. 

The health plan acted reasonably in this instance, and its decision was with sound medical judgment which was in the best interest of the patient because as stated above, the continued stay in a skilled nursing facility (SNF) was not medically necessary with clinical evidence showing the patient was capable of completing most activities of daily living (ADLs). An ongoing skilled nursing facility (SNF) stay was not reasonably expected to be health beneficial for the patient and/or withholding it in whole or in part was not reasonably expected to affect the patient's health adversely as she had been independent with most activities of daily living (ADLs).