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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for skilled nursing facility services from 5/15/21 through 5/22/21.The patient has had recurrent strokes deemed to be cardioembolic in nature, in the setting of chronic atrial fibrillation with high CHADS-VASC score. Each stroke was treated within a short timeframe, with rapid to early restoration of arterial flow, minimizing the extent of damage to the neuronal reservoir, which is the primary determinant of outcomes following stroke according to Alawieh and colleagues. By 5/14/21, the patient had 5-/5 strength on the left side and some mild functional deficits that could be further addressed with rehabilitation in the community setting. Continued stay in a skilled nursing facility in case he had another stroke was not a medical necessity. Observation could have been provided for this purpose in the community by a caregiver.Additionally, the patient had postural dizziness and orthostatic hypotension issues at least since the middle of his acute hospitalization following the second stroke. This was addressed first with fluid repletion, then by medication adjustments and institution of mechanical and behavioral measures such as compression stockings and avoiding rapid position changes. While the patient may have continued to have had some ongoing symptomatology related to this condition, his in-facility medical management for this condition had been maximized as of 5/14/21 and he had been deemed stable for home care and outpatient management by his treating physician. No further skilled nursing facility care was medically necessary related to this issue.The patient was also suspected to have benign paroxysmal positional vertigo and was treated in-facility with Epley maneuvers. According to Mandala and colleagues, canalith repositioning maneuvers (such as the Epley maneuver) are considered the gold standard of treatment for this condition, but recurrences can occur (in 10-20% of cases during the first 2 weeks after treatment), in which case further repetitions of treatment may be necessary. In this case, ongoing inpatient observation and care during this period after an initial canalith repositioning maneuver, however, was not a medical necessity. Further care related to this issue could have been provided in the outpatient setting, including the elective teaching of independent performance of canalith repositioning maneuvers. Long-term management is often required. There are no specific issues in this case that indicated that the patient required ongoing inpatient level care for this condition from 5/15/21 onwards. As noted above, the elective teaching of independent performance of canalith repositioning maneuvers could have been pursued as an outpatient.Therefore, skilled nursing facility services from 5/15/21 through 5/22/21 were not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested services 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.