Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke/CVA
Treatment: Skilled Nursing Facility
The health plan denied the requested admission to a Skilled Nursing Facility. 
The health plan's determination is upheld.

The patient is a male with a history of left cerebellar ischemic stroke as well as recurrent ischemic strokes of the left thalamus. He is currently on preventative treatment including, but not limited to, Aspirin and Warfarin. Additional treatment 
is being targeted for depression, anxiety, stress management, sleep disturbances, and anhedonia. He is currently attending outpatient therapy and requires constant supervision. He is continent of bowel and bladder and safe to wake up and use the restroom independently overnight. He eats a regular diet with thin liquids. He currently has deficits in initiation, sequencing, problem solving, and safety awareness. These have not had meaningful improvement per documentation. Admission to a skilled nursing facility for physical therapy (PT), occupational therapy (OT), and speech therapy (ST) 4 to 6 hours per day for five days per week is being requested.
At issue is the medical necessity of the requested Skilled Nursing Facility admission.

The health plan's determination of medical necessity is upheld.

No. Based on the clinical documentation provided, evidence-based literature and standards of care, a skilled nursing facility admission is not medically necessary.
The patient experienced multiple ischemic strokes, and has current deficits in initiation, memory, sequencing, problem solving, and safety awareness. He is currently receiving outpatient therapy at a rehabilitation hospital.
Bernhardt et al. note the possibility for behavioral changes even years post-stroke is recognized. However, the current understanding of brain repair processes suggests that the majority of behavioral recovery, and the rapid changes occur in the first weeks-to-months post stroke for most people. This time perspective represents an important treatment target to maximize the potential of restorative interventions. The first week until the first month post-stroke (acute and early sub-acute) is a critical time for neural plasticity and should be a target for recovery trials, with some uncertainty about how early and how intensively to start training.[1] In this particular situation, the patient is roughly 6 months post-stroke and has been receiving outpatient therapy services.
Moreover, per the documentation provided, the patient did not require observation and assessment of patient's changing condition to evaluate the need for treatment modification or for additional procedures until the condition stabilized. The patient also did not require skilled care treatments daily such as an intravenous infusion, tube feeding, wound management, oxygen administration, exercise program, urinary or bowel toileting program, gait evaluation and training, therapy modalities that require PT or OT observation to evaluate response, or supervision of therapeutic exercises or activities to ensure patient safety and treatment effectiveness.[2]
Therefore, based on the clinical documentation provided, evidence-based literature and standards of care, a skilled nursing facility admission may be desired but is not medically necessary.