Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke
Treatment: Continued Skilled Nursing Facility (SNF) Care
The insurer denied: Continued Skilled Nursing Facility (SNF) Care
The denial is upheld.

The patient is an adult male with a medical history of a left middle cerebral artery (MCA) stroke with resultant dysarthria, aphasia, and right-sided weakness. Other medical history is notable for hypertension, hyperlipidemia, and obstructive sleep apnea. He was hospitalized and underwent thrombectomy as well as carotid endarterectomy. The patient was transferred to acute inpatient rehabilitation and then to subacute rehabilitation. Prior to his stroke, the patient was independent with mobility and daily activities. With regard to ambulation, upon admission to the skilled nursing facility, the patient was dependent with bed mobility and transfers and non-ambulatory. As of two weeks post admission, the patient was requiring contact guard assistance with bed mobility and moderate to maximum assistance for transfers. He was ambulating 75 feet with moderate assistance with a platform walker. As of one month after that, the patient required stand by assistance with bed mobility, minimal to moderate assistance for transfers and moderate assistance with ambulation with a hemi walker. With regard to self-care, upon admission to the skilled nursing facility, the patient was maximum assistance to dependent with dressing, bathing and toileting. He was moderate assistance for feeding. As of two weeks post admission, the patient was requiring moderate assistance with upper body dressing and maximum assistance for lower body dressing and maximum assistance for bathing. He was dependent for toileting. He was contact guard assistance for feeding. As of one month after that, the patient required supervision for upper body dressing and contact guard assistance for lower body dressing. He required minimal assistance for bathing and moderate assistance for toileting. 

The patient was modified independent with feeding. With regard to communication, upon admission to the skilled nursing facility, the patient had moderate to severe impairment for expressive and receptive language skills and comprehension. As of two weeks post admission, the patient had moderate to severe impairment for expressive and receptive language skills and comprehension. As of one month later, the patient had moderate impairment for expressive and receptive language skills and comprehension. The continued skilled nursing facility care was considered not medically necessary in that it did not meet guideline criteria and that care could have been delivered at a lower level of care.

The continued skilled nursing facility (SNF) stay was not medically necessary.

The patient's conditions did not require the level of observation, evaluation and treatment provided by a physician in the skilled nursing facility for the dates in question. The patient was medically stable and tolerating oral medications. The patient did not require skilled nursing services, including administration of intravenous (IV) medication, wound care, or tube feeding. 

The patient did not have the degree of medical complexity to necessitate care in a skilled nursing facility setting and care that could only be provided in the skilled nursing facility setting. The patient also did not require the level of intensity of skilled therapy services provided in the skilled nursing facility setting. There is insufficient documentation indicating that the patient was receiving ongoing therapy services, and per the documentation the patient's level of function had plateaued.