Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post (s/p) Stroke
Treatment: Continued Skilled Nursing Facility
The insurer denied: Continued Skilled Nursing Facility
The denial is upheld.

The patient is an adult male with a medical history of diabetes mellitus and hypertension who sustained a stroke with resultant dysarthria, dysphagia and hemiplegia. He was independent with mobility and daily activities prior to the stroke. He was admitted to acute inpatient rehabilitation and then a skilled nursing facility. Physical therapy notes indicated that the patient required stand by assistance with transfers and stand by assistance to contact guard assistance when ambulating 200 feet. The patient 
required minimal assistance with transfers and bed mobility and minimal to moderate assistance with walking 35 feet. Occupational therapy notes indicated that the patient required contact guard assistance for lower body dressing.
Occupational therapy documentation indicated that the patient required contact guard assistance with grooming and bathing, minimal assistance toileting and contact guard assistance with lower body dressing. As of the eleventh day, the patient trialed soda and chips as well as thick liquids and was receiving speech therapy. Clinical progress note dated indicated that the patient had no Foley catheter and was not receiving IV (intravenous) medication. Blood sugar was controlled. The continued skilled nursing facility stay was denied coverage by the health plan as not medically necessary per guideline policy, with the rationale that the patient no longer required skilled nursing facility care and that care could be delivered at a lower level. This 
decision is being appealed.

The Continued Skilled Nursing Facility was not medically necessary.

Continued admission to a skilled nursing facility is appropriate for patients with conditions that require observation, evaluation of treatment plans, and updating of orders by a physician as well as constantly available skilled nursing services. Patients require skilled nursing services, including wound management, tracheostomy care, bowel and bladder training and tube feeding, and administration of IV (intravenous) medications or medications that cannot be self-administered safely. They also require skilled nursing observation, including regular monitoring of vital signs, skin in the setting of wounds, and intake and output. Patients typically also benefit from skilled therapy services due to physical limitations, a decline in function or impaired cognition and communication. This includes physical, occupational and speech therapies.

The patient's conditions did not require the level of observation, evaluation and treatment provided by a physician in the skilled nursing facility setting. The patient's medical conditions were controlled, and he did not require IV (intravenous) medication. The patient did not require skilled nursing services, including wound management, administration of IV (intravenous) medication, or tube feeding. He did not require a Foley catheter. The patient also did not require the level of intensity of skilled therapy services provided in the skilled nursing facility setting. His progress had largely plateaued in terms of mobility and performing activities of daily living. He required 
stand by assistance with transfers and stand by assistance to contact guard assistance when ambulating 200 feet. He was requiring stand by assistance to contact guard assistance for the majority of his daily activities.