Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hip Fracture
Treatment: Continued Care in a Skilled Nursing Facility 
The insurer denied the continued care in the skilled nursing facility.
The health plan's determination is upheld.

The patient is a female with a history of a right total hip replacement, a right total hip replacement periprosthetic fracture, right total hip replacement revision surgery, and a right femur nonunion following a total hip replacement revision surgery treated with open reduction internal fixation (ORIF) internal fixation with bone graft to the right femur. Other medical conditions include hypertension, mild asthma, and obstructive sleep apnea. 

Cultures from the right hip were positive for pseudomonas aeruginosa and she was treated with the intravenous antibiotic Cefepime. She had a peripherally inserted central catheter (PICC) line placed and was discharged with Cefepime 2 grams intravenous (IV) every 8 hours to total of 8 weeks of IV antibiotic therapy. She developed cryptogenic organizing pneumonia with hypoxia that improved with IV steroids and was then placed on tapering doses of Prednisone for a few weeks. The patient also had a medical history of hypertension, mild asthma, and obstructive sleep apnea. She was admitted to the hospital then to a Skilled Nursing Facility (SNF). Her treatment at a Subacute Facility, was denied and considered not medically necessary by her Health Plan.

Within a reasonable degree of medical certainty, the health plan, in its determination of medical necessity, acted reasonably, with sound medical judgment and in the best interest of the patient.

Milliman Care Guidelines (MCG) criteria for continued SNF stay include meeting the criteria to qualify for Skilled Nursing Services and Skilled Rehab Services. Skilled services must be required on a daily basis. Skilled nursing services must be required 7 days per week and must include one or more conditions such as treatment with IV injections. The patient does require skilled nursing services due to her need for IV injections, however, she does not need skilled rehabilitation services.
The patient's IV antibiotic treatments could be performed by a home health nurse. The peer-reviewed medical literature in the United States at this time would not include a SNF inpatient stay.

The occupational therapy (OT) evaluation (eval) stated that she required supervision for supine to sit and contact guard assistance for toileting, transfers from wheelchair to bed and wheelchair to toilet. She was independent with feeding, grooming, hygiene, and upper body dressing She required minimal assistance with lower body dressing and bathing. She required moderate assistance with homemaking. The physical therapy (PT) eval stated that her pain level was 6. Right hip passive range of motion was 0 to 90 degrees (). The patient's strength was 3 out of 5 to 4 out of 5. 

There was a time frame where there was no documentation in the OT and PT notes of significant improvement in pain levels, strength, range of motion, function, feeding, hygiene, grooming, upper body dressing, lower body dressing, toileting, bathing, transfers, wheelchair mobility, or ambulation. The patient is independent, contact guard assistance, or supervision with feeding, hygiene, grooming, upper body dressing, lower body dressing, toileting, transfers, and ambulation, and therefore skilled rehab services with PT and OT are not necessary. She is weightbearing as tolerated on the right lower extremity. The patient does not require skilled rehabilitation services and the services are not reasonable and necessary for the treatment of the patient's illnesses and injuries. The patient could participate in a home exercise program to include strengthening and range of motion exercises.