Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spinal cord injury.
Treatment: continued subacute skilled nursing facility (SNF).
The insurer denied coverage for continued subacute skilled nursing facility (SNF).
The denial is upheld.

This case involves an adult who was being managed for a spinal cord injury with ongoing pain management. The patient has limited functionality for activities of daily living and mobility. The patient sustained a traumatic cervical spinal cord injury with incomplete tetra-paresis, with neurogenic bowel/bladder. The documentation provided for the review stated that the patient was admitted to a skilled nursing facility after a fall with head injury and central cord syndrome. The patient was status post open reduction of cervical (C)6-C7 with anterior discectomy and fusion with left foraminal stenosis at C5-C6 and C6-C7, anterior plate fixation at C5-7, with interbody cage at C5-6 and C6-C7. The patient had reports of spasms along with pain and fatigue. When the patient was admitted, the patient was recommended for Physical Therapy, Occupational Therapy, and Speech Therapy. The patient was treated with gabapentin, oxycodone, Tylenol, and baclofen. A speech therapy discharge summary was submitted noting the patient history of an unspecified injury at unspecified level of the cervical spinal cord, unspecified fall, and dysphagia the oropharyngeal phase. The patient continued to receive treatment for the spinal cord injury and comorbidities consisting of benign prostatic hyperplasia without lower urinary tract symptoms, other specified arthritis, unspecified voice and resonance disorder, epistaxis, gastroesophageal reflux disease without esophagitis, chronic sinusitis, unspecified sleep disorder, and unspecified quadriplegia. 

The Milliman Care Guidelines indicates that admission to recovery in a skilled nursing facility or subacute facility care may be needed for patients when all of the following are present: including there are no acute hospital care needs; the patient has intense and complex care needs making recovery facility care safe for and more practical than attempting care at a lower level; and when these care needs include the multiple components of care that are delivered by skilled professionals at a recovery facility, when there is a plan to provide all the following such as a care plan management and evaluation to meet the patient's needs, achieved treatment goals, and ensure medical safety, observation and assessment of the patient's change in condition to evaluate the need for treatment modification or for additional procedures until condition stabilizes, for education services to teach the patient's health maintenance or to teach caregiver patient care, and for skilled care treatments daily that include one more the following such as either nursing treatments or rehabilitation therapy treatments. 

The documentation provided for the review noted that the patient had multiple care needs given the spinal cord injury and associated symptoms. There was a discharge document from the speech and language pathology provided, but no mention of discharge from the occupational and physical therapy nor from the primary treating physician in general. Given that there was no significant improvement in function or reduction in limitations, additional treatment at this level of care is not supported. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for continued subacute skilled nursing facility (SNF) is not substantiated.