Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p (status post) Amputation
Treatment: Continued Alternate Level of Care
The insurer denied the Continued Alternate Level of Care
The denial is upheld

The patient is a male without previously known medical history who was hospitalized  with a poorly healing right foot wound that had occurred two weeks earlier. He was found to be hyperglycemic and was newly diagnosed with diabetes mellitus. He was found to have necrotizing fasciitis of his right lower limb.

The patient underwent a right below knee amputation. He was medically stabilized and transferred to subacute inpatient rehabilitation facility. He underwent preprosthetic rehabilitation and made functional progress. He was ambulating 120 feet with a walker at supervision. He was transferring at supervision. He met with a prosthetist and he was casted for a prosthesis to be delivered in the future. He eventually plateaued functionally. He was transitioned to alternate level of care.

The patient fell on the unit and went to the emergency room overnight. A wound was noted at the bottom of his right residual lower limb and he was instructed to stop wearing his shrinker. He has been receiving topical wound care for this wound since his return to the facility.

Physical therapy noted that the patient was set up for transfers. He was ambulating 200 feet at supervision.

The patient's right leg wound was noted to be improving. His wound care was cleansed with normal saline, patted dry, applied Silvadene cream, covered with gauze, and wrapped with circumferential gauze daily and as needed.

The patient's pain was noted to be well-controlled with his current medications. He was compliant with his diabetic medications, and recent hemoglobin A1c (glycated hemoglobin) was 6.6.

It was reported that the patient's prosthesis was not expected to be delivered for five more weeks.

The patient has not returned to the community. He is reported to have a goal of fully recovering before returning home, including receiving his prosthesis and undergoing training to use it. He is reported to live in a 3rd or 4th floor walkup apartment (different descriptions are given) that also has stairs required to enter the building.

Housing at an alternate apartment was recommended by the health plan, with assistance to be provided by the housing department. Coverage of home services (including assistance with cooking and shopping), as well as transportation to the apartment and subsequent transportation to and from medical appointments, was offered by the health plan. The health plan has ceased covering the patient's facility stay at the alternate level of care (ALOC) level. The health plan denied coverage of the ALOC (alternate level of care) level care, indicating that the records do not show that he is unable or unsafe to be discharged to a lower level of care such as his home.

On an appeal for continued coverage of ALOC (alternate level of care) care, a treating physician noted that the patient's right lower limb wound is now healed. It was noted that there have been delays in procurement and delivery of a prosthesis. The patient was noted to live alone in a 3rd floor walkup apartment and that the railing was damaged. It was noted that he would not be able to climb three floors without a prosthesis without increasing his risk for falls.

No, the continued stay at the facility at the alternate level of care (ALOC) level is not medically necessary.

The standard of care for postamputation rehabilitation begins with promotion of wound healing, desensitization of the residual limb, and gradual shaping of the residual limb aimed towards the fitting of a prosthesis. Preprosthetic therapy should include preventing contractures, working on weight shifting, balancing activities and maintaining/improving cardiovascular and musculoskeletal conditioning, including via use of a wheelchair and via ambulation on the parallel bars without a prosthesis.

A temporary prosthesis is typically fashioned to begin initial weightbearing once the residual limb is sufficiently healed. Prosthetic fitment typically commences no earlier than about six to eight weeks post amputation. Delays in prosthetic fitment due to insufficient wound healing are not uncommon.

Prosthetic training begins with donning and doffing of the prosthesis, skin evaluation and establishment of a progressive prosthetic wearing schedule, generally for 15-20 minutes at the start, before removal for skin checks (Meier RH 3rd and Melton D). Gradually, the time spent wearing the prosthesis is increased until it can be worn all day, a process that can take several weeks to months. Notably, as more time is spent wearing the prosthesis and practicing short bouts of ambulation, the residual limb's shape further matures, which can require adjustments to the prosthesis, potentially lengthening the process further. Specifically, greater levels of activity generally foster residual limb shrinkage (Sanders JE, et al.). Eventually, if proper fitment can be achieved and the tissues become sufficiently conditioned for greater physical demands, the user can wear and use the prosthesis for all-day community level ambulation, as long as their cardiovascular conditioning level will allow.

The prosthetic rehabilitative process, overall, can take many months, if not a year or two or longer, after a prosthesis is first worn. Notably, persons with amputations due to medical pathology/dysvascular conditions (i.e., instead of traumatic amputations) can have a significantly more challenging prosthetic rehabilitation course as their baseline levels of activity can be much lower (Meier RH 3rd and Melton D; Czerniecki JM and Morgenroth DC). In the interim, as prosthetic rehabilitation is pursued, full functional restoration in the absence of a prosthesis is concomitantly pursued. Persons initially hospitalized with a new major lower limb amputation can return to the community when their functional status without a prosthesis sufficiently permits. This can include ambulation via hopping using a walker, or use of a wheelchair, or a combination of the two. Stairs can be negotiated using rails for assistance, and/or using a bumping technique involving sitting on the stairs and using the other limbs to effectuate movement. Prosthetic rehabilitation can be, and is, generally pursued for the most part in the community due to the protracted duration of time that is required, although a short period of inpatient rehabilitation for more intensive therapies can sometimes be appropriate.

In the current case, the patient has completed sufficient pre-prosthetic rehabilitation to return to the community with appropriate durable medical equipment (e.g., a walker) and some assistance (e.g., for some higher level self-care such as bathing, and for instrumental activities of daily living such as cooking/meal preparation and shopping). He is at a set up level for transfers and no more than supervision level for ambulating household distances. His environmental barriers can be addressed via transportation services for his initial community reintegration and medical appointment needs, as well as making arrangements with the community for emergency evacuation needs (e.g., by notifying the local fire department), and through home-based therapy services to work on his negotiation of the stairs without a prosthesis, which should be feasible with training and practice. Alternatively, an alternate community setting (e.g., relatives' or friend's homes, or other alternative housing arrangement) can be considered. The patient can otherwise receive nursing services in the community for wound care and medical follow up in an ambulatory setting. There are no active medical issues requiring ongoing care in an institutional setting.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The health plan appropriately denied coverage of the requested service given that the service is not needed for the patient's care, as discussed above. It is not reasonable, appropriate, or healthy for a person to remain in an institutional setting for a protracted period of time when a community disposition is feasible with appropriate preparation and arrangements. It is not reasonable or necessary to remain in an institutional setting after a leg amputation for the time required to procure a prosthesis, train with a prosthesis, and become proficient with a prosthesis, i.e., sufficient enough for the user to negotiate multiple flights of stairs. This process is generally very protracted and more appropriately and reasonably pursued in the community setting to everyone's advantage, including the person with the leg amputation.