Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mild cognitive impairment, attention-deficit/hyperactivity disorder (ADHD), ulcerative colitis.

Treatment: Care in a Skilled Nursing Facility (SNF).

The insurer denied coverage for care in a Skilled Nursing Facility (SNF).

The denial is upheld.

According to the documentation submitted, this is the case of a female patient with a past medical history of mild cognitive impairment, attention-deficit/hyperactivity disorder (ADHD), ulcerative colitis, treatment- resistant epilepsy with atonic/astatic semiology. The patient was admitted for acute inpatient rehabilitation status post anterior craniectomy callosotomy. The patient's treatment course has included Physical Therapy (PT), Occupational Therapy (OT), and Speech and Language Therapy. Discharge planning notes state that the patient will need sub-acute rehabilitation care. 

It is not medically necessary for the patient to be transferred to a subacute facility on a date yet to be determined. The patient has met all her rehab goals and the need for transfer was due to her need for safety supervision. This transfer is for custodial care and is not based on medical necessity. This decision is based on generally accepted practice guidelines by the federal government and professional medical societies.

Physical therapy (PT) notes as documented stated that the patient was ambulating 100 feet twice with right hand-held assist and support around the trunk. She transfers sit to stand with contact guard assistance. In Occupational therapy, the patient requires close supervision for oral care with verbal cueing to attend to task. She also requires hand over hand assist to initiate hair care and is able to complete the task with verbal cueing. She has met her short and long term goals per the Speech and Langauge Pathologist. Included in the short term goals that were met are "was that she would imitate verbal expressions to maintain topic across three consecutive communication exchanges."  Long term goals were also met at Speech Therapy including" stating three opinions to presented basic to semi-complex topics with minimal support." 

The patient's previous functional status(baseline) as documented in the therapist's report showed that the patient requires assistive equipment and person for transfers and ambulation. She also requires assistive person for toileting, bathing, dressing, eating. She has no problems with swallowing and communicating both receptively and expressively.

Ampac Basic Mobility Score showed that the patient needed a little help for most of the tasks. This score and the current functional reports from the different therapists (physical, occupational and speech) show that the patient is at baseline functional status. She does not need skilled nursing care, which is care provided by a skilled nurse at a skilled nursing facility. 

The patient lives with her mother; however, mother works full time.  The Attending Physician's note states that the patient is not safe to discharge to home since the patient needs 24/7 supervision for safety but the mother works. She also receives home care services provided by Managed Long Term Care (MLTC) 5.5 hours per day.  Records show that the request for transfer to SNF is due to her need for safety supervision. This is custodial and not medical necessity. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for care in a Skilled Nursing Facility (SNF) is upheld. Medical necessity is not substantiated.