Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal 
Treatment: Skilled Nursing Facility 
The insurer denied Nursing Home Services. 
The denial is overturned in whole. 

The patient is a male with a history of obstructive hydrocephalus, cirrhosis with thrombocytopenia, diabetes mellitus type 2, anxiety and depression, history of alcohol abuse, history of polysubstance abuse, chronic right shoulder dislocation with deformity, hypertension and hyperlipidemia. He had been hospitalized with obstructive hydrocephalus and subsequently transferred to a rehabilitation facility. The patient received rehabilitation services with physical therapy (PT) and occupational therapy (OT), skilled nursing services and the patient was considered to be permanent placement and not expected to return to community setting. There was a request by the rehabilitation facility requesting custodial services authorization. The patient had a fall and resumed OT and PT services with discontinuation of OT and PT. Physical therapy discharge summary noted the patient had improved upper extremity strength on the right, required contact-guard assistance with ambulation, required minimal assistance with wheelchair mobility, and required minimal assistance with stairs. The Occupational Therapy discharge summary noted the patient was able to maintain standing balance without support against minimal resistance, required minimal assistance with self-feeding, set up for hygiene and grooming, moderate assistance with bathing, minimal assistance with toileting, set up for dressing upper and lower body, and required minimal assistance with problem solving.

The insurer had sent final adverse denial determination notice, upholding initial adverse determination denial notice to not approve request for custodial care. The denial stated the patient was able to go to the bathroom with help and the patient's needs could be met in a community setting. During the patient's stay at the rehabilitation facility, the patient received methadone monitoring and treatment, monthly psychiatric visit, dietitian visits, and physical and occupational therapy.

At issue is the medical necessity of Nursing Home Services.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Nursing Home Services is medically necessary for this patient.

The patient had a functional and cognitive decline following hospitalization for obstructive hydrocephalus. The patient had noted poor insight and judgment throughout his rehabilitation stay. The patient had a history of alcohol and polysubstance use and underlying psychiatric disorder with methadone treatment also not allowing him to return to the community. The patient was noted to have chronic right shoulder dislocation with deformity. The patient required help with all instrumental activities of daily living (IADLs) and some activities of daily living (ADLs). The patient did have a fall and continued with ongoing skilled services with OT and PT. There were documented notes from PT and OT that the patient had improvement and progression from his initial admission to rehabilitation.

Therefore, the requested health service/treatment of Nursing Home Services is medically necessary.