Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Skilled Nursing Facility (Custodial). 
The insurer denied custodial long term care institutional. 
The denial is overturned. 

The patient is a male with a past medical history significant for hypertension, diabetes mellitus, atrial fibrillation, congestive heart failure (CHF), right (Rt) below knee amputation (BKA), and opioid dependence who was admitted to an extended care center. The subject under review is the medical necessity for custodial long term care institutional. 

Custodial care refers to services ordinarily provided by personnel like nurses' aides and consists of any non-medical care that can reasonably and safely be provided by non-licensed caregivers.

The custodial care can take place at home or in a nursing home. The custodial care involves help with daily activities like bathing and dressing. In some cases where care is received at home, care can also include help with household duties such as cooking and laundry.

Examples of Custodial Care, include, but are not limited to, the following:
1)	Assistance in dressing, eating, and toileting;
2)	Periodic turning and positioning in bed;
3)	Prophylactic and palliative skin care, including bathing and application of creams, or treatment of minor skin problems;
4)	Stable bolus feeding by nasogastric, gastrostomy, or jejunostomy tube;
5)	Routine care of the incontinent individual, including the use of diapers and protective sheets;
6)	Routine services to maintain satisfactory functioning of indwelling bladder catheters;
7)	General maintenance care of colostomy and ileostomy;
8)	General supervision of exercises, which have been taught to the individual and do not require skilled rehabilitation personnel for their performance. This includes, but is not limited to repetitive exercises to maintain function, improve gait, or maintain strength or endurance; or passive exercises to maintain range of motion in paralyzed extremities, or assisted walking;
9)	Daily supervision and assistance with dressing, eating, and hygiene for an individual with severe and persistent mental illness with findings such as cognitive impairment, delusions, and hallucinations that interfere with an individual's ability to live in the community;
10)	 Changes of dressings for non-infected postoperative or chronic conditions;
11)	 Administration of routine oral medications, eye drops, and ointments;
12)	 Chronic uncomplicated oral or tracheal suctioning.

The review of the medical records demonstrated that this individual definitely required custodial care due to complex medical problems, decreased mobility, and psychiatric conditions that would preclude him from getting adequate care at home.
At the beginning of the hospitalization, this patient required administration of intravenous antibiotics administered through the peripherally inserted central catheter (PICC) line daily. In addition, this patient had intermittent episodes of diarrhea that would affect his hygiene in the setting of decreased ambulation due to previous BKA.
Furthermore, this patient had a large number of medications that were prescribed and should be administered in a timely manner. He required significant assistance with ambulation.
Furthermore, this patient required ongoing wound care due to multiple skin ulcers. This included dressing changes. 
There was a significant risk of clinical deterioration that would necessitate admission to the hospital.
The custodial long-term care was medically necessary due to a variety of different factors including the patient's physical and mental limitations related to his psychiatric illness and disability related to BKA. The patient needed administration of intravenous antibiotics for the first 28 days. He had tremors that affected his ability to function independently, therefore, he required significant help with activities of daily living including the administration of medications.