Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic schizophrenia.
Treatment: Room and Board Custodial Care.
The insurer denied the Room and Board Custodial Care.
The denial is upheld. 

The records report that the health plan member is a female with a history of chronic schizophrenia.  The member's other pertinent medical history includes anxiety, a chronic neck deformity, osteoarthritis and visual impairment affecting both eyes.  She is reported to be blind.  The only pertinent health condition specifically related to vision documented in the available records is cataracts. The duration that she has had visual impairment is not documented.  Several years ago, she did have a fall resulting in a right hip fracture.
It is reported that, at baseline, the member was living at a group home type setting due to her schizophrenia.  She has been there for an unspecified period of time, although she was residing there or in a group home setting.  Her only documented contact is a case worker.  Other social history is not documented in significant detail.  Functionally, at baseline, she was ambulating with a Rollator at supervision. She received some custodial level assistance for some self-care tasks such as bathing and dressing. She required max assist for instrumental activities of daily living.
The records indicate that the member was transferred to a skilled nursing facility because the group home type facility where she had been residing closed that day.  There was no documented change in the member's condition overall that had prompted the transfer, other than the closing of her residence.  There were no documented recent hospitalizations, emergency room visits, health care provider encounters or other encounters that prompted the change in placement.
At the skilled nursing facility, the member's vitals have been stable.  She has been generally oriented, but has required some reality reorientation and redirection from staff.  Hearing has been noted to be adequate.  She has been verbal and able to communicate her needs.  She was noted to be a little anxious, which was attributed to the change to a new environment.  She has otherwise been behaviorally stable.  A psychiatric evaluation noted that she was stable from the psychiatric standpoint.  She has been intermittently incontinent of urine.  She has been continent of bowels.  There has been no leg edema.  There have been no significant pain issues.  X-rays of her left knee showed no acute findings.  She has been risperidone, sertraline, aspirin, famotidine, atorvastatin, eye drops, topical analgesics, oral acetaminophen and vitamins.

The health plan member has been at her baseline level of function, which is requiring custodial level help due to her schizophrenia and visual impairments.  She was residing at a group home and was stable using a walker for mobility and receiving some limited assistance for some of her self-care tasks, as well as significant help with instrumental activities of daily living.
There was no change in the member's health or functional condition warranting a change in the level of her care beyond her usual baseline level of care. There was no need for new skilled therapy, skilled nursing, or medical care at a skilled nursing facility.  The member's care could have been continued in a group home type setting with her usual level of custodial assistance. Skilled nursing facility level care has not been medically necessary based on the available records.

Speech therapy assessed the member and noted no swallowing issues. She was having some chewing difficulties due to poor dentition.  Physical and occupational therapy have been following the member.  She was found to require min assist for some of her self-care tasks.  She has been able to walk, wearing a Wanderguard on her wrist/hand.

The member has had chronic functional impairments.  She did need a new group home to reside in because her prior group home had closed.  She did not require a skilled nursing facility level of care. The health plan reasonably denied coverage of the skilled nursing facility level of care in question.