Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spinal surgery.
Treatment: Continued Stay Skilled Nursing Facility.

The insurer denied the Continued Stay Skilled Nursing Facility.  The denial is upheld. 

The patient is a male. The patient has a history of cervical spine fracture.  He underwent rehabilitation and ultimately regained his ability to ambulate.

The patient underwent a C6-T2 (sixth cervical spine vertebra - second thoracic spine vertebra) spinal fusion.

The patient underwent spinal surgery from the T9 (ninth thoracic spine vertebra) level to the pelvis, with osteotomies at the L2-3 (second lumbar spine vertebra - third lumbar spine vertebra) and L3-4 (third lumbar spine vertebra - fourth lumbar spine vertebra) levels, and decompressions at the L2-3 (second lumbar spine vertebra - third lumbar spine vertebra) and L5-S1 (fifth lumbar spine vertebra - first sacral vertebra) levels.

The patient was transferred to a skilled nursing facility for further care. His baseline was noted to be non-ambulatory.  He was using a scooter for most mobility.  He was crawling for short distances in the home.  He was transferring by Hoyer lift.  He was sleeping on a yoga mat.  He was independent with showers and dressing.

Physical therapy noted that the patient's family could use the mechanical lift to transfer him at home, but they could not "be there all day."  The family desired him to be independent during the day, and they would be there "later in day/night."  It was noted that it was difficult finding home health aides at the present time due to the COVID pandemic.  It was noted by the facility's social worker that the patient was "ready for discharge at this time."  He was going to go to his sister's home until he is ready to return to his own apartment.  His family stated that they "will want an [aide] to assist him with getting ready for the day, every day."

Physical therapy noted that the patient was stand by assist for bed mobility and total assist for transfers.

The patient was transferring by Hoyer lift.  He was non-ambulatory.  He was independent with upper body dressing.  He was dependent for lower body dressing.  He was requiring assistance for bathing.  He was using a bedpan for toileting.

No, the Continued Stay Skilled Nursing Facility was not medically necessary.

The records indicate that the patient has a baseline of being non-ambulatory and requiring total assist for transfers.  He was independent with showers and dressing in a modified manner.  The patient underwent extensive spinal surgery from the lower thoracic spinal levels down to the pelvis.  He subsequently underwent extensive rehabilitation.  He continued to require total assist for lower body dressing, as well as physical assistance for bathing and toileting.  He was ready for community reintegration at that time with custodial level assistance for his transfers and much of his self-care.  There were no indications at that time that he was making or was reasonably expected to make substantial functional gains in a predictable manner in the near term.  Further rehabilitation, if indicated, could have been pursued in the community setting.  The ongoing skilled nursing facility level care in question was not medically necessary.

The patient had previously been more independent but underwent extensive spinal surgery and had a persistent change in his self-care ability afterwards that was not improving in a significant manner with rehabilitation.  He was ready to return to the community with custodial level care that was increased from his baseline level of custodial level care where he was dependent with mechanical lift transfers at home.  The ongoing care at the facility was custodial in nature and not medically necessary.