Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Skilled Nursing Facility. 
The insurer denied Custodial and respite care. 
The denial is overturned in whole. 

The patient is a male with past medical history of atrial fibrillation, hypertension, congestive heart failure, benign prostatic hyperplasia (BPH), scrotal wound, and right hip osteoarthritis who had been admitted to rehabilitation. The patient was seen by cardiology and noted to have signs of volume congestion with a diagnosis of hypertension, congestive heart failure, and atrial flutter on anticoagulation. The patient had a Patient Review Instrument (PRI) noting no decubitus ulcer, the ability for patient to feed himself without supervision or physical assistance, the ability to walk with intermittent supervision requiring human assistance for difficult parts of walking, requiring intermittent supervision and/or physical assistance for difficult maneuvers with transfers, requiring intermittent supervision for safety or encouragement or minor physical assistance for toileting, as well as patient participating in restorative therapy within the past week.The patient signed custodial nursing home placement and institutional Medicaid acknowledgement. There was a request from the facility for custodial coverage. The physician placed an order stating, "this is a long-term patient". The insurer sent a final adverse determination denial notice denying coverage for custodial and respite care as not medically necessary. The denial stated the following criteria must be met: There is a signed physician order for long-term care placement, Patient Review Instrument (PRI), and custodial agreement must be submitted. In addition, the denial stated criteria were not met because after reasonable unsuccessful attempts by telephone for required clinical need for long-term care/custodial admission, the custodial admission in a nursing facility was denied due to lack of additional clinical information. The denial stated there was no custodial agreement or signed physician order for long-term care placement and this was required for long-term care placement. A discharge summary was written noting the patient had progressed well and completed rehabilitation and was returning to home. The discharge summary noted the patient's blood pressure and heart failure as well as atrial fibrillation had been well controlled. There was a plan for home care, cardiology follow-up, and urology follow-up for scrotal wound. The patient appealed the denial decision stating insurance stated they did not receive necessary documentation, required specifically long-term care (LTC) agreement form which had been submitted in a timely basis.
At issue is the medical necessity of Custodial and respite care.

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

The requested health service/treatment of Custodial and respite care medically necessary for this patient.
The patient had a PRI and did have an order placed by the provider as well as completion of the custodial nursing home placement and institutional Medicaid acknowledgement. The insurer stated they tried to reach the facility while the facility stated they attempted to reach the insurer multiple times. The facility and the patient had completed appropriate paperwork/documentation for the request for custodial care. The PRI stated the patient required intermittent supervision and/or physical assistance for difficult maneuvers with transfers, requiring intermittent supervision for safety or encouragement or minor physical assistance for toileting, as well as he was a patient participating in restorative therapy within the past week.
Therefore, the requested health service/treatment of Custodial and respite care is medically necessary.