Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  
Skilled Nursing Facilty
The insurer denied the Skilled Nursing Facility.
The determination is overturned.

The patient has diagnoses significant for paraplegia, status/post (s/p) cervical fusion/laminectomy cervical (C) 4-5, neurogenic bowel and neurogenic bladder. He was originally admitted to inpatient rehabilitation on and discharged to a skilled nursing facility (SNF). At issue is whether the requested health service/treatment of skilled nursing facility stay  was medically necessary for this patient.

The requested service of skilled nursing facility is medically necessary for this patient. The patient is a male with paraplegia. He has a new spinal cord injury. He was admitted to acute inpatient rehabilitation and was discharged to a SNF. At the time of discharge from acute inpatient rehabilitation, therapy documented that the patient required minimal assistance (MINA) to perform self-feeding with a vertical palmer utensil in the right upper extremity (RUE) and was able to eat 50% of his meal before fatiguing. He required MINA to perform oral care and maximal assistance (MAXA) to don a shirt. In addition, bilateral shoulder flexion and abduction range of motion had greatly improved (flexion from 0-90 degrees to 0-130 degrees; right shoulder abduction from 0-90 degrees to 0-160 degrees; left shoulder abduction improved from 0-80 degrees to 0-140 degrees.). Therapy noted hip flexion, 2+/5 right and 2/5 left. Hip extension 2/5, bilaterally. Hip abduction 1/5, bilaterally. Right knee extension 2+/5 and left knee extension 3/5. Right ankle dorsiflexion 0/5 and left 2+/5. Right plantar flexion 1/5 and left 3/5. Right great toe extension 2/5 and left 1+/5. Given this degree of strength, therapy documented "Pt able to stand with moderate assistance (modA) x1, minA x1 once standing with or without B UE on assistive device." The patient also ambulated in an exoskeleton "over 300 steps in one session and was able to use 40% of own muscle strength bilaterally to perform stepping." Therapy discharged him and stated "Pt's time limited 2/2 to public health emergency related to COVID-19 pandemic. Pt made slow, steady progress throughout stay and has potential for vast improvement" For example, pt this week was able to consistently perform popover transfer with moderate assist, rolling on mat with minAx1 and improved sitting balance."
Given all of the above information, it is not clear how the therapist documented that self-feeding, hygiene/grooming and upper body dressing required total dependence w/o attempts to initiate. This goes against everything from acute inpatient rehabilitation and does not describe the same person. Therapy notes continued to document total dependence with varying notation of whether the patient was attempting or not. It would be expected for this patient to be severely deconditioned as documentation noted that he was quarantined to his room for 14 days. A patient with a chronic spinal cord injury needs daily stretching, multiple times a day, and someone with a new spinal cord injury, such as this patient, would need even more extensive care. Therefore, it is not surprising that therapy documented poor endurance and an inability to perform static sitting or dynamic sitting. A skilled nursing facility stay is medically necessary as it will take time for the patient to regain the function lost during his 2 weeks of quarantine where minimal therapy was completed.