Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders/Cellulitis.
Treatment: Skilled Nursing Facility.
The health plan denied the requested continued skilled nursing facility stay. 
The health plan's determination is upheld.

Per the medical records, this male patient is status post transtibial/below the knee amputation (BKA) on the right lower extremity (RLE), secondary to cellulitis and dry gangrene with a recent debridement secondary to infection. The patient had prior extensive surgical interventions in the RLE with a right first toe amputation, a right foot transmetatarsal amputation, RLE angiogram and debridement  followed by a RLE balloon angioplasty followed by a right BKA and closure. The patient's past medical history includes peripheral vascular disease, diabetes mellitus (DM), hypertension (HTN), hyperlipidemia, and anemia. Per the documentation received, prior to admission, the patient was living in a shelter and was independent with all activities of daily living (ADLs) .
According to the documentation provided, the patient was not eligible for prosthetic training during the time period in question due to the right residual limb wound. The patient could receive outpatient physical therapy for the goals listed in the letter from the rehabilitation facility "to increase functional activity tolerance, increase lower extremity (LE) range of motion (ROM) and strength and improve ability to perform basic ADLs with increased independence and safety." During this stay at the Skilled Nursing Facility (SNF), the patient had follow-up with vascular surgery and the patient was informed of the possibility that he may require further surgery, namely an above the knee (transfemoral) amputation (AKA).
At issue is the medical necessity for the requested Skilled Nursing Facility Services.

I uphold, in whole, the health plan's determination of medical necessity.

Criteria for inpatient skilled nursing includes that the patient must show active participation in physical, occupational, or speech therapy for a minimum of 1 hour per day and 5 days per week. In addition, documentation must demonstrate sustained gains, progress towards pre-established goals, improvement in function and reduction in limitations. For the time period in question, the patient did not meet these criteria, as he was not making functional gains. For the time period in question, the patient did not have complex skilled nursing needs. He did not require intravenous or intramuscular medication management. He was not dependent on parenteral nutrition. The patient did not have complex wound care needs.
Continued stay at the SNF was not medically necessary. The patient's right BKA wound with sutures could have been appropriately cared for at an alternate level of care. The patient was not eligible for prosthetic training during the time period in question due to the right residual limb wound. He could have received physical therapy at an alternate level of care for the goals listed from the rehabilitation facility which were, "to increase functional activity tolerance, increase LE ROM and strength and improve ability to perform basic ADLs with increased independence and safety." These are goals which do not necessitate a SNF level of care.