Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Hip fracture. 
Treatment: Inpatient rehabilitation (continued care in a Skilled Nursing Facility). 
The insurer denied coverage for inpatient rehabilitation (continued care in a Skilled Nursing Facility). 
The denial is modified. 

According to the documentation submitted, this is an adult with a history of a right hip fracture, hypertension, and anemia. The patient presented to the rehabilitation facility from the hospital for rehabilitation services after hip surgery. During the admission the patient participated in physical therapy and occupational therapy (PT & OT). Many of the patient's OT goals were met by a specific date. The patient was able to walk 10 feet independently. The patient was discharged home with services.  

The insurer has denied coverage for a continued skilled nursing facility (SNF) stay to discharge as not medically necessary. In a Final Adverse Determination letter, they stated that the plan clinical criteria considers continued care in an SNF to be medically necessary when the following criteria are met: 1) the patient is showing therapeutic response to treatment; 2) the patient is participating in a rehabilitation program; 3) the patient needs skilled services that cannot be met at a lower level of care; 4) the patient is making progress in therapy. The patient did not meet criteria for a continued SNF stay. The requested admission is denied based on Milliman Care Guidelines using the guideline of Medical Admission Recovery Facility Care: Hip Fracture, Open Repair (ORG: S-5600). 

The patient is appealing. In an appeal letter, the patient stated that they had hip surgery. The patient was admitted to the rehabilitation facility for rehabilitation services after surgery. The entire SNF stay was needed. 

This is patient who sustained a right hip fracture on and subsequent surgical repair.  The patient was transferred to a skilled nursing facility (SNF) and discharged home.  Under review is the medical necessity for continued SNF stay to discharge.

The patient was initially an appropriate candidate for the SNF subacute rehabilitation level of care (1, 2, 3). The patient received physical and occupational therapy during their stay with excellent functional recovery. According to the occupational therapy notes, the patient was independent with general hygiene, dressing and transfer activities. A similar level of progress was noted by the physical therapist. The patient was independent with bed mobility and able to ambulate with supervision approximately 150 feet. However, the treatment notes, there was evidence of possible surgical wound infection. Laboratory blood studies were obtained, and the patient was placed on oral antibiotics. Subsequent nursing notes document treatment of the surgical wound as routine and the patient could have been discharged home. Based on clinical records, it would have been reasonable to continue SNF level of care for wound care evaluation and treatment with an earlier discharge date. 

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, a continued SNF stay was not medically necessary. However, SNF initially was medically necessary. 

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for a continued skilled nursing facility (SNF) is not substantiated. However, SNF was initially medically necessary.