Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Renal Failure
Treatment: Long term acute care hospital (LTACH)
The insurer denied: LTACH
The denial is: Overturned

The patient is a male who is currently hospitalized. He was admitted with acute cholecystitis, septic shock due to Escherichia (E) coli bacteremia, and rhabdomyolysis. He developed acute kidney injury leading to acute renal failure requiring hemodialysis. He also presented with respiratory failure and is still requiring bi-level positive airway pressure (BiPAP). He was admitted and has been deemed stable for discharge by his medical team. He is not a candidate for skilled nursing facility (SNF) placement due to his constellation of needs but has been medically accepted to a Long Term Acute Care Hospital (LTACH). This LTACH admission was denied as the patient did not meet criteria for LTACH admission. This is the subject under review.  
  
The patient required initiation of dialysis due to his renal failure and is still requiring multiple weekly sessions. He became functionally debilitated as a consequence of his severe illness and the fall that he presented with. He was independent at home prior to admission but is currently not able to get out of bed. His care is complicated by morbid obesity (weight 453 pounds with body mass index [BMI] of 63). He therefore has required bedside hemodialysis, which cannot be provided by Skilled Nursing Facility (SNF). He also still requires BiPAP throughout the night and as needed during the day as he recovers from respiratory failure. Thus, he also requires access to BiPAP during hemodialysis sessions.
Recent daily progress notes were provided for review. They indicate that the patient had tunneled hemodialysis catheter placed and is getting dialysis multiple times weekly. Nephrology notes indicate that there is evidence of renal recovery.
Case management notes indicate that SNF referrals were denied because the patient exceeds their care capacity due to his needs. He currently has a medical need for bedside hemodialysis and access to BiPAP during sessions, which they cannot provide. They are also on a waiting list for a bariatric bed for hemodialysis.
The subject under review is the medical necessity for admission to LTACH.

The health plan's determination is overturned.

In order to determine if the patient is appropriate for admission to LTACH several standard criteria are considered.
The patient should be stable for transfer. Based on the notes and physician assessment, the patient appears medically stable for transfer.
The patient has need for care by several types of specialists. The patient is currently receiving care from nephrology, infectious disease, and hospitalist medicine. Additionally, he has significant functional/mobility requirements requiring significant nursing intervention and ongoing physical therapy (PT)/occupational therapy (OT). He is also receiving wound care due to trauma from his falls as well as pannus fungal infection.
Documentation/assessments show that the patient is expected to make improvement. In this case the patient has not yet plateaued. The recent nephrology notes say that renal function is still improving. It may be several months before they can determine if his need for dialysis will be permanent or not. From a functional standpoint, he was independent at home prior to this admission. We do not know what his new functional baseline is at this point. He will benefit from ongoing therapy to improve functional capacity.
Documentation supports the need for prolonged care. This patient will almost certainly need several months of ongoing rehabilitation and medical care.
Documentation shows that LTAC is the most appropriate level of care for this patient over lower levels of care such as Skilled Nursing Facility (SNF) or home health care (HHC). Therefore, Long Term Acute Care Hospital (LTACH) is the more appropriate setting for care and is medically necessary for the patient.