Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Broken Leg, Bones With an Infection
Treatment: Continued Sub-Acute Rehabilitation Stay
The insurer denied the Continued Sub-Acute Rehabilitation Stay.
The denial is upheld.

The patient is a male with history of stress fracture of tibia and fibula. He had an external fixation, which was removed. He was experiencing difficulty in functional mobility, decrease in strength, decreased ambulation, decreased endurance, reduced dynamic balance and increased fall risks.

The patient has relevant past medical history of CAD (coronary artery disease) status post coronary bypass, hypertension, hyperlipidemia, mitral valve disease, foot fracture. The patient has prior history of a fall, sustaining Right Tibia/Fibula fracture. He was status post ORIF (open reduction internal fixation) with splint that became infected. This was treated with IV (intravenous) antibiotics.

The patient was Weight-Bearing-As-Tolerated (WBAT). He was admitted to Subacute Nursing Facility (SNF). Prior to admission, he was independent with ADLs (activities of daily living) and living alone in a 2-level house with steps to get to the second floor where his kitchen, bedroom and bathroom are located. The plan is to discharge him home with help from others that will include arrangements by social worker for visiting nurse, home health aide and continue home PT (physical therapy).

The patient is able to ambulate 150 feet with aid of crutches, able to go up 12 steps with aid on one handrail, required supervision or set-up with grooming, feeding, toileting, bed-mobility, transfers, toilet transfers, tub-transfers, Car-transfer, Independent with lower body and upper body dressing/bathing, . The plan was to discharge him home.

No, the Continued Sub-Acute Rehabilitation Stay is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The continued care was not medically necessary and should not be covered by the health plan because the patient has not met all the criteria for sub-acute rehabilitation care under INTERQUAL Criteria for Subacute/SNF (skilled nursing facility) Criteria Acute Neurological (SAC-SNF). The patient was admitted to SNF (skilled nursing facility). He is able to ambulate 150 feet with aid of crutches, able to go up 12 steps with aid on one handrail, required supervision or set-up with grooming, feeding, toileting, bed-mobility, transfers, toilet transfers, tub-transfers, Car-transfer, Independent with lower body and upper body dressing/bathing. The plan was to discharge him home.

The patient's concern about navigating 46 steps and being unsafe are addressed, as social work evaluation pointed to a flight of stairs from the first floor to the second floor as stated above, for which his ability to navigate 12 steps using handrail should suffice along with the fact that he is getting a visiting nurse, health aid and continue rehabilitation with home therapy. He has not shown greater improvement in his ADLs (activities of daily living) for period of 2 weeks. This is a key reason why continued rehabilitation in his home environment with home therapy will be the next appropriate thing, as his continued stay in the SNF (skilled nursing facility) is more custodial at this point.

Therefore, the plan has appropriately denied coverage, and the patient will be better served continuing with an outpatient rehabilitation or home therapy as the discharge plan was towards this with plan for his discharge.