Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infectious Disease/Other/Covid 19
Treatment: Skilled Nursing Facility Services

The health plan denied the requested continued skilled nursing facility services.  The health plan's determination is overturned.

The patient is a female with a past medical history of morbid obesity, ovarian cancer, overactive bladder and bilateral lower extremity lymphedema with dermatitis who was hospitalized with a Covid 19 infection and subsequent rehabilitation stay. The patient had a deep vein thrombosis (DVT) and pulmonary embolism (PE) and was hospitalized again with transfer back to rehabilitation. The patient was noted to have a recurrent pressure wound of her back and was seen by a wound care provider for recommendations with documentation that the wound had resolved. The patient was receiving Oxycodone and Gabapentin for pain. The social work notes stated the patient's goal was to return to prior level of functioning to return to the community home; the patient had a lack of formal/informal supports in the community, had a recent hospitalization, was working with therapy and making progress, and a lower level of care such as assisted living program (ALP) would not be appropriate due to her age and level of care needed at the time. Later social work notes stated the patient's goal was to return to her community apartment with a roommate; the roommate could not assist with any activities of daily living (ADLs), the patient still had lack of informal/formal supports, durable medical equipment (DME) may need to be ordered prior to discharge, continued to work with therapy and make progress, was not appropriate for alternate living arrangements such as ALP as she required a higher level of assistance than what an ALP could provide. 

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

Yes. The patient has a history of morbid obesity, chronic lymphedema, chronic lower extremity dermatitis, significant knee pain, Covid 19 infection, DVT, PE, lower back pressure sore, and pneumonia. The skilled services are provided under the supervision of the physician. Care plans specified individual realistic goals and discharge plans as noted in occupational therapy (OT), physical therapy (PT), and social work notes. Provided services were expected to result in measurable and significant improvement in the patient's condition within a reasonable time frame, however, the patient did have setbacks with DVT, PE, left knee pain, pressure wound, pneumonia, and edema. The patient was medically stable and appropriate at the skilled nursing facility. The patient was not appropriate for a lower level of care, given her skilled therapy needs. The patient was receiving one or more skilled therapies or skilled nursing services at least once a day. The patient demonstrated ability and willingness to participate in care plan. The patient had active management of complex medication regimen including anticoagulants, antibiotic, and diuretic therapy. For a period of time the patient did have wound care. There was a documented decline in functional status related to illness and disease. The patient was able to actively participate with OT and PT and demonstrated rehabilitation potential. In summary, the requested health service/treatment of continued skilled nursing facility services are medically necessary for this patient.