Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain
Treatment: Continued Inpatient Stay In Skilled Nursing Facility
The insurer denied the Continued Inpatient Stay In Skilled Nursing Facility.
The denial is overturned.

The patient is a male with history of low back pain with general debility, several falls due to weakness of bilateral lower extremities due to lumbar herniated discs and sciatica.  He has a relevant past medical history of hypertension, sepsis, respiratory failure, chronic kidney disease, liver cirrhosis, chronic obstructive pulmonary disease (COPD), anemia, muscle weakness, gait instability, sacral decubitus ulcer, etc

Prior to admission, the patient was living with family members and was independent and the plan is to discharge him back.  He was admitted to skilled nursing facility (SNF).  He required wound care, bilateral lower extremity muscle strength was 2/5 and he required maximum assistance times two for most activities of daily living (ADLs) and total dependence for toilet transfers. 

The patient did not require wound care, bilateral lower extremity muscle strength was 3/5, transfers required minimum assistance, he was ambulating 40 feet with moderate assistance, able to navigate three steps with maximum assistance, and grooming/upper body dressing was with supervision.  He was still having issues with falls and was a safety issue.  He has chronic obstructive pulmonary disease requiring oxygen (O2) two liters nasal canula (2L/NC) as needed.

The prior denial was because the patient was not showing tangible improvement.  The reason for appeal is because the patient has not met his rehabilitation goals and is still with high fall risks while showing progress as stated above.

Yes, the proposed continued stay in the skilled nursing facility was medically necessary.

The continued stay in skilled nursing facility was medically necessary because the patient was admitted to the skilled nursing facility, required wound care, bilateral lower extremity muscle strength was 2/5 and he required maximum assistance time two for most activities of daily living (ADLs) and was total dependence for toilet transfers.

The patient did not require wound care, bilateral lower extremity muscle strength was 3/5, transfers required minimum assistance, he was ambulating 40 feet with moderate assistance, able to navigate three steps with maximum assistance, grooming/upper body dressing was with supervision.  He was still having issues with falls and was a safety issue.  He had chronic obstructive pulmonary disease requiring oxygen (O2) at two liters nasal canula (2L/NC) as needed.

Therefore, continued stay in the skilled nursing facility was medically necessary as the patient's activities of daily living (ADLs) level was improving and he was still a high risk for falls while having chronic obstructive pulmonary disease (COPD) requiring oxygen at two liters nasal canula.  The patient's needs cannot be met at a lower level of care such as outpatient physical therapy (PT) / occupational therapy (OT) or home therapy.

No, the health plan did not act reasonably in this instance, and its decision was without sound medical judgment which was not in the best interest of the patient.
As stated above, the continued stay in skilled nursing facility was medically necessary with clinical evidence as stated above and the continued stay in skilled nursing facility is reasonably expected to be health beneficial for the patient and/or withholding it in whole or in part be reasonably expected to affect the patient's health adversely as the patient is still weak and a fall risk while he continues to show progress.