Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Brain Injury
Treatment: Continued Skilled Nursing Facility
The insurer denied the Continued Skilled Nursing Facility.
The denial is upheld. 

The patient is a male.  His baseline is independent.  He was working as a taxi driver.  The patient developed a brain injury due to a subarachnoid hemorrhage due to a ruptured posterior communicating artery aneurysm due to untreated hypertension.  He underwent coil embolization.  The patient was transferred to a skilled nursing facility for further care.

The patient was maximum assist for transfers.  He was non-ambulatory.  He participated in multidisciplinary rehabilitation. Three months later, he was moderate assist for ambulating 60 feet. A nursing noted that the patient was requiring 2-person assist for transfers and total care for activities of daily living.  Approximately a month later, the patient was minimum assist for transfers.  He was moderate assist for ambulating 75 feet. The patient's care at the skilled nursing facility was covered by the health plan throughout until a specific end date.

The patient's affect was unchanged.  There were no focal neurological deficits.  He was on a chopped consistency diet.  He was incontinent of bowel and bladder.  He was upgraded to a regular consistency oral diet.  He was minimum assist for transfers.  He was ambulating 75 feet at moderate assist. The patient removed his gastrostomy tube himself.  The ex-gastrostomy stoma site was noted not to be bleeding. The patient was transferred to the hospital for an angiogram.  He was admitted due to hydrocephalus. He underwent ventriculoperitoneal shunt placement. The patient returned to the skilled nursing facility.

The patient was moderate assist for transfers.  A nursing noted that he was noncompliant with transfers and wheelchair usage. A nursing noted that he was very difficult to redirect. The patient was noted to be wandering a lot in his wheelchair. He was noted to be wheeling himself.  He was removing his clothes frequently. He went for a neurosurgery appointment.  The patient was noted to be very restless and requiring frequent redirection not to enter other patient's rooms. He was on a regular consistency diet.  He was incontinent of bowel and bladder.  He was noted to be wandering in the hallways and to be very difficult to redirect.  He was transferred to the emergency room due to chest pain.  He returned shortly thereafter.  There was no further chest pain. 

A nursing noted that the patient was alert but confused. He was noted to be agitated and wanting to go home.  He was poorly redirectable. He was restless and difficult to redirect. He was restless, wandering the hallways and difficult to redirect.  He was confused, wandering and required redirection. He was noted to be wandering a lot in the hallways. He reported loss of vision in his right eye. He was cleared by physical therapy to no longer need a gait aide or wheelchair.  He was found by physical therapy to be modified independent for transfers.  He was reported to be ambulating 100 feet at contact guard assist.  He was seen by an ophthalmologist, who noted right retinal detachment.  A procedure was performed.  He was to be seen by a retinal specialist emergently.

The patient was sent to the emergency room regarding his right eye.  He was started on various eye drops and an eye shield.  He was to follow up with the eye doctor in one week.  He was noted by physiatry to be doing much better off of Seroquel.  

The patient was ambulating in his room.  He developed a headache. He went to the hospital for a head computed tomography (CT).  The study showed a slight increase in his chronic subdural collections.  It was noted that his computed tomography (CT) of the head was further reviewed and the plan was direct admission to the hospital for a ventriculoperitoneal shunt revision.

The patient was ambulating unlimited distances without an assistive device.  He was incontinent of bowel and bladder.  He was discharged to the hospital for a shunt revision.

No, the proposed skilled nursing facility was not medically necessary.

The patient sustained a severe brain injury due to an aneurysmal rupture due to untreated hypertension.  During the initial part of his skilled nursing facility stay, he made some functional improvements from a nonmobile state to a level where he was mobile but was primarily functionally impaired due to cognitive impairments.  He was at a custodial level of care where he needed supervision and redirection for his wandering and confusion.  He continued to require extensive self-care from nursing.  He remained incontinent of bowel and bladder.  He was otherwise tolerating an oral diet.  Skilled nursing facility was not medically necessary.