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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for skilled nursing facility (SNF) services. The records document that this patient has multiple chronic medical conditions associated with long-term health problems and functional difficulties including heart disease, diabetes, kidney disease, and arthropathy. At premorbid baseline, the patient was using a walker, but was independent with basic self-care and basic mobility. He was documented as requiring assistance with his instrumental activities of daily living at baseline. The patient had multiple acute hospital care episodes related to anemia, congestive heart failure, renal failure, urinary obstruction, dehydration and near syncope. He developed general physical debility and was dependent for essentially all aspects of care. There was also reports of confusion. The patient underwent therapy and convalesced at a SNF. However, the records do not report that the patient substantively improved during this time. The patient was discharged to the long-term care unit of the facility. He was at a low functional level at the time and required total assistance for all mobility. Over the ensuing months, the patient demonstrated generalized functional improvement without documented skilled therapy intervention. On therapy re-assessment, the patient required contact guard to minimum assistance for transfers and ambulating short distances with a walker at minimum assistance. The patient required set up for upper body self-care such as feeding and upper body dressing. There are no documented indications that therapy continued after the assessment. The patient was cleared for leaves of absence from the facility with family. He underwent further therapy, but he was essentially requiring cues and contact guard assistance to complete his basic self-care and mobility tasks. He continued to require significant levels of cues despite the ongoing therapy. There were no indications that this level of supervision and assistance could not have been supplied by custodial level caregivers in the community or that the patient was benefiting from formal therapy services. He had chronic medical issues but no ongoing issues requiring inpatient level care or monitoring. He was receiving medical care consistent with outpatient level care and his nursing needs were custodial. The indwelling urinary catheter was no longer an acutely placed device but a chronically maintained device. All told, the SNF services were not medically necessary for treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 physical medicine and rehabilitation 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.