Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Unspecified Fracture of the Right Foot
Treatment: Skilled Nursing Facility (SNF) Inpatient Stay
The insurer denied the skilled nursing facility inpatient stay.
The health plan's determination is upheld.

The patient is a female with a history of a right ankle fracture dislocation, status post (S/P) right ankle open reduction internal fixation (ORIF), hypertension and weakness. She was admitted to a rehabilitation center. She was independent with feeding, standby assistance for bed mobility, hygiene grooming and upper body dressing. She was contact guard assistance for transfers and lower body dressing. She was contact guard to minimum assistance for toileting and required minimum assistance with ambulation for 50 feet with a rolling walker. She was minimum assistance for bathing. She was unable to do stairs. Less than a week later she was independent with feeding, standby assistance for bed mobility, hygiene grooming, and upper body dressing. She was contact guard assistance for transfers, lower body dressing, toileting and ambulation of 70 feet with a rolling walker. She was contact guard to minimum assistance for bathing. She was unable to do stairs. The following month she was independent with feeding, supervision for hygiene and grooming and set up for upper body dressing. The patient was standby assistance for lower body dressing and contact guard for toileting and bathing. She was independent with mobility and activities of daily living (ADL's) prior to admission.

The health plan, in its determination of medical necessity, acted reasonably, with sound medical judgment and in the best interest of the patient. The patient has a history of right ankle fracture dislocation, S/P right ankle ORIF, hypertension and weakness. Skilled rehabilitation services with physical therapy (PT) and occupational therapy (OT) are not necessary. The patient was partial weightbearing on the right lower extremity. As of the requested start date for the skilled nursing facility inpatient stay, the patient could participate in a home exercise program to include strengthening and range of motion exercises.

Her incisions were healing well and she could get them wet. She would wear the right ankle boot at all times except for active range of motion exercises and icing. Her weight bearing was at 25 percent (%). She was independent with feeding, supervision for hygiene and grooming, set up for upper body dressing, standby assistance for lower body dressing, and contact guard for toileting and bathing. The patient was awake, conscious, and coherent with no signs or symptoms of distress. The day after the request for the skilled nursing facility inpatient stay, her weight bearing status was increased to 50%. The following week her weight bearing status was increased to 75%.

Milliman Care Guidelines (MCG) criteria for service and treatment at a SNF include meeting one or more criteria to qualify for Skilled Nursing Services, Skilled Rehabilitation Services, or both. Skilled nursing services must be required 7 days per week and must include one or more conditions such as treatment of Stage III or IV pressure ulcers, a widespread skin disorder, open lesions, intravenous (IV) injections, IV fluids, enteral feedings, trach care, suprapubic catheter care or uncontrolled pain. The patient's pain is well controlled and her vital signs are stable. She did not require IV fluids or antibiotics and her wounds have healed.