Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sepsis following spinal surgery. 
Treatment: Continued stay at a Skilled Nursing Facility. 
The insurer denied the continued stay at a Skilled Nursing Facility. 
The determination is overturned. 

This is a male patient admitted to a skilled nursing facility for care after being treated for sepsis following a spinal surgery. 
The patient was originally admitted to the hospital for a lumbar laminectomy with spinal fusion. He was readmitted to the hospital with an increase in back pain and fever. He was found to have septic shock and was admitted to the intensive care unit (ICU). He had bacteremia which grew Morganella and Proteus species. After his acute inpatient stay, he was admitted to the skilled nursing facility. 
The patient was being treated in the skilled nursing facility with intravenous antibiotics for several weeks when he again appeared to be septic. He was readmitted to the acute care hospital. During that hospitalization, he was treated for sepsis. His postoperative course was complicated by two episodes of acute hypoxic respiratory failure and acute kidney injury. He was eventually stabilized and discharged back to the skilled nursing facility for ongoing care. He was at maximal assistance for bed mobility and upper body activities. 
The patient's therapy progress was reviewed in detail. The patient's bilateral upper extremity strength had improved from a baseline of 3 plus (+) to 4 minus (-). He was still unable to transfer to a bedside commode without assistance. He was unable to perform item retrieval without assistance. He remained under two-person, total assistance care. His skin was notable for an unstageable coccyx pressure ulcer.
The patient was followed by a wound care specialist while in the hospital. He had report of a stage 4 pressure wound on the left buttock for at least one month's duration. Daily wound care treatments were ordered for the patient. 
At issue is the medical necessity for a skilled nursing facility stay. 

The requested health service of Skilled Nursing Facility (SNF) Care is medically necessary for this patient. The patient had a remarkably complicated medical course following his lumbar spinal surgery. He was hospitalized with sepsis, and subsequently rehospitalized for a prolonged period due to ongoing sepsis and acute respiratory failure. He had a very large fluid collection which required drainage and a subsequent repeat procedure. In total, he spent well over a month in the acute care hospital spread out over multiple hospitalizations. He was discharged to the nursing facility in a condition that required total dependence and assistance for all activities of daily living. He also had a stage 4 pressure ulcer. His hospitalization resulted in significant debility requiring prolonged rehabilitation. It is not reasonable that the health plan recommended that he be discharged from skilled nursing after only one month from his last hospitalization for sepsis. His improvement was expected to be very slow given the prolonged period of time that he required in the hospital. He was eventually able to be safely discharged, but not for approximately another six months. The progress notes demonstrate that the patient required ongoing skilled nursing level of care as well as ongoing intensive therapy services to maximize his recovery potential. The ongoing stay in the skilled nursing facility was medically necessary and reasonable for the patient.