Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Brachial plexopathy
Treatment: Continued Therapy and Services In Skilled Nursing Facility (continued sub-acute rehabilitation)
The insurer denied: Continued Therapy and Services In Skilled Nursing Facility (continued sub-acute rehabilitation)
The denial is overturned.

The patient is an adult male. He was initially admitted with dyspnea. He later had CABG (coronary artery bypass graft) and developed brachial plexopathy, resulting in weakness of both upper extremities and also pain in both lower extremities. He was hospitalized in acute hospital care for nearly two months. 
The patient's relevant past medical history includes coronary artery disease, myocardial infarction, diabetes mellitus, hypertension, peripheral artery disease, et cetera. He has a history of right below-knee amputation with left fifth toe amputation. Prior to admission, the patient was independent and lived alone in a house. He worked driving trucks. The house has eight steps-to-enter, with bilateral rails. He had a right BKA (below-knee amputation) prosthetic.
The patient was admitted to SNF (skilled nursing facility) mostly totally dependent for most ADLs (activities of daily living). As of six weeks post admission, he was still totally dependent in most ADLs (activities of daily living), including lower body dressing, upper body dressing, toileting, toilet/commode.

The patient requires supervision with functional mobility during ADLs (activities of daily living). The patient is able to navigate 150 feet. He is unable to navigate stairs. He requires minimum assistance with dynamic standing, requires moderate assistance with self-feeding, requires maximum assistance for hygiene/grooming, bed mobility, et cetera.

The requested continued therapy and services In a Skilled Nursing Facility (continued sub-acute rehabilitation) is medically necessary.
The patient had CABG (coronary artery bypass graft) and developed brachial plexopathy, resulting in weakness of both upper extremities and also pain in both lower extremities. He was hospitalized in acute hospital care for nearly two months. His relevant past medical history includes coronary artery disease, myocardial infarction, diabetes mellitus, hypertension, peripheral artery disease, et cetera. He has history of right below-knee amputation with left fifth toe amputation.

The patient was admitted to SNF (skilled nursing facility) mostly totally dependent for most ADLs (activities of daily living). As of six weeks post admission, he was still totally dependent in most ADLs (activities of daily living), including lower body dressing, upper body dressing, toileting, toilet/commode.

The patient requires supervision with functional mobility during ADLs (activities of daily living). He is able to navigate 150 feet. He is unable to navigate stairs. He requires minimum assistance with dynamic standing, requires moderate assistance with self-feeding, requires maximum assistance for hygiene/grooming, bed mobility, et cetera.

Based on the above and late progress associated with multiple medical issues and co-morbidities, continued stay in SNF (skilled nursing facility) was medically necessary towards continued improvement before discharge.