Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke; Difficulty Ambulating
Treatment: Skilled Nursing Facility (SNF) Admission
The insurer denied the Skilled Nursing Facility (SNF) Admission.
The health plan's determination is upheld.

The patient is a female with a history of deep vein thrombosis (DVT) and pulmonary embolism (PE) (on chronic oral anticoagulation). She also has a history of a stroke, left sided weakness, left sided facial droop, slurred speech and difficulty ambulating. A magnetic resonance imaging (MRI) of her brain showed a subacute infarction in the right periventricular white matter with possible involvement of the right caudate nucleus body. During the course of her hospitalization, her symptoms gradually improved. She had persistent left-hand numbness and an unsteady gait. She was discharged to a nursing home. Since her arrival, there were no acute concerns.

The requested health service/treatment of a skilled nursing facility (SNF) admission is not medically necessary for the patient. The physical and occupational therapy notes stated that her lower extremity strength was 3 out of 5. The patient required supervision to contact guard assistance for transfers and she ambulated 150 feet with standby assistance. She was able to walk up 7 steps with contact guard assistance and she required minimal assistance for hygiene, grooming, bathing, and lower body dressing. She required moderate assistance for upper body dressing.

The medical note stated that her vital signs were normal, her blood pressure was 128/61, her temperature was 97.9, her respirations were 18, her pulse was 62, and her oxygen saturation was at 97 percent (%).  She was alert, oriented, pleasant and able to follow commands. The patient's strength was normal in her bilateral upper and lower extremities. She had an appropriate mood and affect and she was conversant.

The Milliman Care Guidelines (MCG) criteria for a SNF admission (based on scientific evidence, professional standards and expert opinion) have not been met as there is no need for skilled nursing or skilled rehab in the setting of pain that is under control. The patient had no wound care needs, no intravenous (IV) fluid needs, no IV antibiotic needs and she had stable vital signs. There was no documentation of a significant improvement in bathing, dressing, bed mobility, transfers, ambulation, grooming, or feeding. MCG criteria for the requested health service/treatment of a skilled nursing facility (SNF) admission includes meeting one or more criteria to qualify for Skilled Nursing Services, Skilled Rehabilitation Services, or both. Skilled services must be required on a daily basis. The patient's functional or medical complexity must be such that the outcome would be compromised with less than daily skilled services.
Multiple skilled nursing services must be required 7 days per week and must include one or more conditions such as treatment of a Stage III or IV pressure ulcers, a widespread skin disorder, complex wounds requiring a registered nurse or licensed practical nurse (RN/LPN) to complete wound treatment, IV injections, IV fluids, enteral feedings, nebulizers, colostomy care, tracheostomy care, urinary catheter care, or uncontrolled pain. The patient's pain was well controlled and her vital signs are stable. She does not need IV fluids or antibiotics and there are no complex wound needs, and therefore skilled nursing is not necessary.

The patient could participate in a lower level of care, such as a home exercise program to include strengthening and range of motion exercises. The peer-reviewed medical literature in the United States at this time would not include the requested health service/treatment of skilled nursing facility (SNF) admission for the patient. Further, the medical standard of care would not include the requested health service/treatment of a skilled nursing facility (SNF) admission for the patient.