Appeal type: Medical necessity
Decision: Upheld

Diagnosis: General debility; Weakness
Treatment: Long Term Care Placement 
The insurer denied the Long Term Care Placement 
The denial is upheld. 

The patient is a female with general debility and weakness post-Covid infection. Her relevant medical history includes hypertension, obesity, rheumatoid arthritis, Congestive heart failure, pulmonary hypertension/embolism, hypothyroidism, Atrial Fibrillation, coronary artery disease, GERD (gastroesophageal reflux disease), Ulcerative colitis, peripheral vascular disease, etc.

Prior to admission, the patient was independent with ADLs (activities of daily living) and living with her daughter.

The patient was admitted to long term care. Approximately four months later she was ambulating 25' x 2 using RW (rolling walker) with supervision, required supervision for supine-to sit, sit-to-stand, stand pivot with verbal cues, requiring moderate assistance x 2 to navigate stairs with 2 hand rails, required set-up for feeding/grooming/hygiene, required minimum assistance for upper body dressing, required maximum assistance for toileting, lower body bath/dressing, while patient remained motivated, continued to participate in therapy sessions and showing progress. She was also having difficult with swallowing which was regular diet with thin liquid. There were also concerns on fall risks and safety by the therapists.

Approximately a month later, there was no documented tangible improvement in the patient's status, with main improvement ambulation at 50' x 2.

No, the Long Term Care Placement (custodial admission in nursing facility) is not medically necessary.
The patient was admitted to a Long-Term Care facility. Approximately four months later, she was ambulating 25' x 2 using RW (rolling walker) with supervision, required supervision for supine-to sit, sit-to-stand, stand pivot with verbal cues, requiring moderate assistance x 2 to navigate stairs with 2 hand rails, required set-up for feeding/grooming/hygiene, required minimum assistance for upper body dressing, required  maximum assistance for toileting, lower body bath/dressing, while patient remained motivated, continued to participate in therapy sessions and showing progress. She was also having difficult with swallowing which was regular diet with thin liquid. There were also concerns on fall risks and safety by the therapists.

Approximately a month later, there was no documented tangible improvement in her status with main improvement ambulation at 50' x 2. Therefore, continued stay in long term care was not medically necessary, as the patient's ADLs (activities of daily living) level had not shown documented tangible improvement towards a need for further stay in long term care while she remained medically stable. Also, her needs can be met at a lower level of care such as outpatient PT/OT (physical therapy/occupational therapy) or Home therapy with or without Health aides.

The continued stay in long term care was not medically necessary, with clinical evidence as stated above showing no documented tangible progress while she was also clinically stable and no ongoing acute clinical issues. Further stay in long term care was not reasonably expected to be health beneficial for the patient, and/or withholding it, in whole or in part, was not reasonably expected to affect the patient's health adversely.