Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for in-patient acute level of care services.Irmak and colleagues state that, although reconstruction is still a controversial issue in elderly patients with advanced pressure ulcers, it has been established that infection, protein loss, morbidity, and mortality will increase in patients without proper debridement and reconstruction. Appropriate patient selection, debridement, and reconstruction with appropriate postoperative rehabilitation can be very beneficial in elderly patients. In patients whose general health condition is a contraindication for surgery, at a minimum, progression of pressure ulcers can be prevented with good wound care and conservative treatment. Bhattacharya and Mishra state that negative pressure wound therapy is an invaluable tool in the management of pressure sores and involves the application of sub-atmospheric pressure to a wound using a computerized unit to intermittently or continuously convey negative pressure to promote wound healing. Negative pressure wound therapy is effective for deep, cavitating, infected and copiously discharging pressure ulcers, particularly with exposed bone.In this case, the patient is a chronically ill male who was admitted to the hospital with septic shock and organ failure. The patient also had stage IV decubiti of his heal and sacrum. The acute life-threatening problems that caused the patients hospitalization were successfully managed, and he was able to be transferred to standard acute hospital care. A heel decubitus was debrided and covered with a skin graft. A sacral decubitus was debrided, and observation showed necrosis and poor healing. Because of the patients poor healing, the wound VAC that was placed after the excision was used for subsequent therapy as well. Submitted documentation reflects that the patient continues with supportive care for his sacral decubitus and his chronic health issues. During the periods under review, the patient was not, and is not, receiving hospital treatment for acute illness. The VAC therapy that the patient has received is an appropriate method of management for his sacral decubitus. Because of the patients multiple health issues, he would not be a candidate for transfer to a nursing home. As acute problems requiring hospital care were not present during the periods under review, the patient could have been, and could be properly cared for in a skilled nursing facility during those periods. Accordingly, in-patient acute level of care services provided during the periods under review were not, and are not, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were not, and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.