Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p (status post) Back Surgery
Treatment: Continued Skilled Nursing Care
The insurer denied the Continued Skilled Nursing Care. 
The denial is upheld. 

The patient is a female who has a history of depression, hypertension, morbid obesity and bilateral knee replacements.

Earlier this year, the patient underwent spinal surgery for resection of an extramedullary mass at the T8-9 (thoracic vertebrae) level causing spinal cord compression.  Her hospital course was complicated by pneumonia and a right popliteal deep venous thrombosis.  An inferior vena cava filter was placed.  The patient was transferred to acute inpatient rehabilitation for further care.  She was found to have a left popliteal deep venous thrombosis.  Apixaban anticoagulation was started.

The patient was transferred to a skilled nursing facility for further care.  She was noted to be incontinent of bladder and bowel.  Her baseline was noted to be living in the community with her family.  She was staying with her sister on the second floor of a two story residence requiring five steps to enter, plus a flight up to the living space.  Her mother and an uncle were residing on the first floor.  She was using a walker at an independent level at baseline but was using a wheelchair for a few weeks prior to hospitalization.  She was generally requiring a limited amount of assistance to perform her self-care and instrumental activities of daily living tasks at baseline.  She participated in a therapy program.

The patient was moderate assist for bed mobility and transfers.  She was maximum assist for toilet transfers and toileting.  She was minimum assist for dressing.  She was maximum assist for bathing.  She was ambulating ten feet at moderate assist.

The patient was minimum assist for bed mobility, transfers and toileting.  She was stand by assist for dressing.  She was moderate assist for bathing.  She was ambulating 30 feet with a walker at moderate assist.

The patient was minimum assist for bed mobility.  She was contact guard assist for transfers, and minimum assist for toilet transfers.  She was stand by assist for toileting and bathing.  She was set up to stand by assist for dressing.  She was ambulating 50 feet with a walker at minimum assist.

The patient was stand by assist for bed mobility, transfers (including toilet transfers), toileting, and ambulating 90 feet with a walker.  She was supervision for lower body dressing.

The patient was stand by assist for transfers (including toilet transfers), toileting, and ambulating 100 feet with a walker.  She was supervision for bed mobility, bathing and lower body dressing.  She was minimum assist for negotiating eight steps.

The patient was stand by assist for toilet transfers and negotiating 13 steps.  She was supervision for bed mobility, transfers (except toilet transfers), bathing, lower body dressing and ambulating 175 feet with a walker.  

The patient ultimately left the facility.  She was unable to negotiate the steps into her residence.  She stayed at a friend's home that had no steps required to enter.  She subsequently returned home and required help from her neighbors to get her up the stairs.  She was visited by home physical therapy.  The patient attempted to go down the stairs and fell on her bottom.  An additional bannister was subsequently installed between the first and second floors.  She has been having difficulty dressing herself at home.

No, the proposed continued skilled nursing care is not medically necessary.

The patient was ambulating with a walker independently but required some assistance with some activities of daily living at baseline.  Her baseline conditions included morbid obesity and bilateral knee replacement surgeries.  She developed further functional impairments due to a thoracic spine level tumor causing spinal cord compression.  She underwent spinal decompression in late spring followed by acute inpatient rehabilitation. She was transferred to a skilled nursing facility for further care.  She made functional progress.

The patient was at the supervision to stand by assist level for her household level mobility and self-care.  Further care could have been provided in the community with custodial level assistance.  Further inpatient level rehabilitation solely or primarily to work on negotiating environmental barriers making community reintegration more convenient was not medically necessary.  The patient, notably, was able to stay temporarily at a friend's residence without stairs upon discharge from the facility.  Other options could have included staying in a commercial property such as a hotel, an assisted living facility, or a custodial facility until a more accessible long-term residential living situation more befitting of the patient's chronic mobility and functional impairments could be secured.  An extra banister in the home could have been installed well prior to the patient's return to the community.