Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Laryngeal Cancer. 
Treatment: Continued skilled nursing facility level 1. 
The insurer denied continued skilled nursing facility level 1. 
The health plan's determination is overturned. 

The patient is a female with a medical history notable for weakness and laryngeal cancer. The patient was residing at a skilled nursing facility for care. Her medical history is notable for hypertension, diabetes, anxiety, depression, and dementia. The patient was diagnosed with laryngeal cancer and underwent a total laryngectomy, partial pharyngectomy, and hemithyroidectomy with partial reconstruction. Following her stay in the inpatient setting, she was discharged to the skilled nursing facility for further care and subacute rehabilitation. 
The skilled nursing facility provided a letter of support for this appeal. The letter states that the rehabilitation has increased her recovery. The patient is improving in her self-sufficiency. They believe that the patient requires ongoing therapy to preserve and improve her level of function. 
The health plan denied the request for ongoing care. They state that the patient must meet their criteria for continued stay in the skilled nursing facility. She must not be eligible to continue receiving her care at a lower level. The plan believes that the patient could have been safely discharged for continued care in the home setting or in long term care. The plan applied Milliman Care Guidelines (MCG) care guidelines for recovery facility care in making their determination. 

The requested health service of Skilled Nursing Facility - Level 1 is medically necessary for this patient. Therapy notes were provided for review. The occupational therapist notes that the patient demonstrates excellent rehabilitation potential. They also state that the "patient's functional performance is improving as a result of skilled treatment and improvement to reach prior level of function (PLOF) is anticipated." Physical therapy notes report improvement in strength of the extremities from a baseline of 3 out of 5 at admission to 4 plus (+) out of 5 (with a prior level of functioning at 5 out of 5). Her other domains returned to near baseline but were not quite to PLOF. The physical therapist discharged the patient with notation that the patient made consistent progress but had "reached maximum potential with skilled services." She was then recertified for skilled services extending with a goal to reach her prior level of functioning before her surgery. The patient's goal was to be able to safely return home where she lives alone. She was able to live alone prior to her surgery. 
The patient is showing a good response to treatment. She shows excellent recovery potential given the fact that she was functioning independently prior to her surgery. She had a major procedure and required physical and occupational therapy to regain function. She also required speech therapy given her extensive neck surgery. She showed continued improvement and her team believes that she will continue to do so. Therefore, continuing care in the skilled setting is medically necessary and appropriate for the patient. 

The health plan's determination of medical necessity is overturned in whole.