Appeal type: Medical necessity
Decision: Upheld


Diagnosis: shortness of breath
Treatment: continued skilled nursing facility
The insurer denied: continued skilled nursing facility
The denial is Upheld.

The patient is a male transferred to a skilled nursing facility after treatment in the hospital for shortness of breath and tachypnea with hypoxemia, requiring nonrebreather mask therapy secondary to coronavirus disease 2019 (COVID-19). He was treated with Remdesivir for five days and gradually transitioned to a high-flow nasal cannula. His hospital course was complicated by melena, requiring transfusion of 3 units of blood, further decompensating his respiratory status. Once the patient was stabilized, he was transitioned to a skilled nursing facility. When he was evaluated in the rehab, he required extensive assistance for med mobility and x (times) 2 assistance for transfers with a gait belt. He was still requiring oxygen. Before discharge, he was placed on iron tablets and a proton pump inhibitor (PPI).
The patient participated in rehabilitation but had a rocky course at the facility. There was a fall incident. There were no significant injuries; he bent down and fell out of bed. He was instructed to use turn handles in the bed. It is noted that the patient's vision is relatively poor.
A psychiatrist was asked to evaluate the patient, who noted the patient is alert and oriented x 3 and not cognitively impaired. They recommended no psychotropic medications. The patient continued therapy; an extension for rehabilitation services was requested; however, it was declined. The nursing home filed an appeal, and the patient remained in the hospital.
The patient experienced an acute episode of hypotension. He had concurrent nausea during this hypotensive episode. A 500 milliliter (mL) normal saline bolus was given, and labs were drawn. The patient had a chest x-ray which showed persistent infiltrates. The nursing home attending started Augmentin and doxycycline for ten days. On abdominal 
x-ray, the patient was found to have a large stool, possibly causing nausea. He was given a tap water enema as well as senna and Colace. 
The following week the patient was participating in therapies, making slow but steady progress. The patient was documented to have a stage I pressure injury to the right heel and stage I pressure injury to the left heel. He was ambulating approximately 50 feet with a rolling walker. Regarding assistance, the patient requires limited assist x1 for medical mobility, extensive assistance for transfers, and extensive assist for ambulation.
A second extension for skilled nursing care was requested. However, this was denied, as the patient was not making significant further progress. The subject under review is the medical necessity for continued skilled nursing facility care.

Continued skilled nursing facility care is not medically necessary based on the provided documentation. The patient underwent skilled nursing facility treatment, during this time  he underwent physical therapy, had minor complications caused by orthostatic hypotension, questionable bacterial pneumonia, and required ongoing oxygen supplementation. Based on the last progress note, the patient is medically stable, on a stable regimen of medications, without significant medical needs being addressed. The patient still requires extensive assistance with ambulation and transfers. After more than five weeks in a skilled nursing facility, the patient has not returned to his previous level of functioning. It is challenging to conclude from the documentation that the patient is poised to make significant measurable gains to return to his previous level of functioning with further skilled nursing facility care.
In conclusion, continued skilled nursing facility care is not medically necessary.