Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

 The enrollee is requesting authorization and coverage, and reimbursement, for skilled nursing facility (SNF) services. The enrollee was admitted to a skilled nursing facility (SNF) for the treatment of severe left hip osteoarthritis status post left total hip arthroplasty. The records indicate the enrollee received skilled physical therapy (PT)/occupational therapy (OT) services to enhance functional mobility skills and activities of daily living (ADLs). The enrollee was able to ambulate 35 feet with one rest period using a front wheel walker and requiring minimal assistance. Her physical status was touch down weight bearing. As part of the discharge plan, durable medical equipment, including a walker and home care referral were prescribed. However, the enrollee did not feel safe for home discharge because she was walking on tippy toes only, and could not walk. She requested to stay at the SNF until her weight-bearing (WB) status changed, which was projected to be in three more weeks. Review of the record indicates in the skilled nursing facility discharge summary, the enrollees condition and performance were reviewed with the director of rehabilitation, RN case manager, extended care coordinator, and social services three times a week in the interdisciplinary team meeting. Their assessment of the enrollees restoration potential by the discharge date indicates there was no expectation that continued skilled services would result in improvement of the enrollees condition materially in a reasonable and generally predictable period of time. Further, skilled services were not necessary for the establishment of a safe and effective maintenance program. Maintenance care needs could be addressed safely and effectively through the use of non-skilled personnel, such as home health aides and the expected results of skilled and rehabilitative services were insignificant in relation to the extent and duration of skilled and rehabilitative services that would be required to achieve those results. As a result, this discharge summary concluded that continued skilled and rehabilitative services were not reasonable and not necessary for this enrollee. Consistent with the discharge summary evaluation and decision for discharge, the medical literature indicates support for skilled nursing facility/rehabilitation after total joint arthroplasty is based on physical therapy achievements. The physician reviewer found that the study found longer stays in nursing facilities are associated with substantial adverse health events and high hospital readmission rates. Based on this enrollees records, her clinical progress at the skilled nursing facility was not complicated by intensive/complex care needs. Rather, by the time the enrollee was considered for discharge, she was able to stand with minimal assistance and walk with a front wheel walker. Although she was unable to fully bear-weight at the time of discharge, this was not the expected goal for enrollee discharge from the skilled nursing facility. Her care was expected to continue at home with the assistance of home health aides, PT and OT. The SNF care team did not consider the enrollees medical status required further care at the SNF level. The enrollee received care at the SNF for approximately 2.5 weeks. Based on the literature, this is within the average length of stay at the SNF for patients after total joint arthroplasty. Further if the patients goals are met (which the record indicates they have been in this case), literature supports safe discharge. Final Result: The reviewer determined that the requested services were not medically necessary for the treatment of the enrollees medical condition.