Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation, hypertension, hyperlipidemia,
diabetes mellitus, foot ulcer
Treatment: Continued Stay Skilled Nursing Facility
The insurer denied the Continued Stay Skilled Nursing Facility
The denial is upheld. 

The records report that the patient is a male with a past history of atrial fibrillation, hypertension, hyperlipidemia and diabetes mellitus with foot ulcer.  He lives with his sister and brother-in-law.

The patient was hospitalized with sepsis due to osteomyelitis.  He was treated with intravenous antibiotics.  His diabetic foot ulcer (on the right lateral foot) was debrided.  He was placed on non-weightbearing restrictions for his right leg.

The patient was transferred to a skilled nursing facility for further care, including completion of his intravenous antibiotics (ertapenem once daily, to complete a four week course) via a peripherally inserted central line.  He was on apixaban anticoagulation for his atrial fibrillation.  Cognition, speech and swallowing were assessed to be within normal limits.

Nursing noted the patient was "walking in the room with no crutches."

The patient had swelling of his right toes.  It was noted that he was noncompliant with non-weightbearing restrictions for his right leg.  Education was continued about rationale for non-weightbearing restrictions.

The patient noted that his sister is a nurse and that he could get his wound care at home.  He also stated that he was going to a hyperbaric wound treatment center previously.  Therapy was to work on his negotiation of stairs towards returning to the community.

The patient was on oral antibiotics.
	
The patient was to return home, but he remained at the facility "due to being followed by wound doctor here in facility."  He was also noted to have tested positive on a COVID-19 screen by rapid testing, while asymptomatic.  There was no prior history of COVID-19 infection.  He had not been vaccinated.  He was started on intravenous banana bag (for three days) and intravenous antibody infusion.

The patient remained asymptomatic from the COVID standpoint.  He was supervision to contact guard assist for self-care.  The plan was continued intravenous banana bag.

The patient was ambulating 225 feet at set up level.  He was negotiating 15 steps at stand by assist.  It was noted that the discharge was cancelled because he was COVID positive.  

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

Per the facility's plan, the patient was ready for discharge to the community.  He stayed longer due to convenience because his wound care provider was at the facility.  He had a chronic diabetic foot wound.  Chronic diabetic foot wounds can be treated as an outpatient.  The patient was on oral antibiotics and did not have any other care needs that required ongoing skilled nursing facility level care, including any rehabilitation needs.

The stay was further prolonged by a positive COVID-19 screen test, the rationale for which was not documented.  He was asymptomatic at the time.  He empirically received intravenous antibody therapy which was completed.  He empirically received multiday doses of intravenous fluid and vitamin supplementation ("banana bags"), which have no proven clinical efficacy in the setting of any infectious condition, including asymptomatic COVID-19 infection.  There was no indication for a multiday course of this intravenous fluid and vitamin supplementation, particularly given that the patient had no incapacity to drink fluids or consume oral vitamins.  The patient could have returned to the community before and quarantined as needed.

Therefore, the continued stay skilled nursing facility was not medically necessary.

There was no necessity of prolonged care at the skilled nursing facility level of care for wound care, rehabilitation or asymptomatic COVID-19 infection care.  There would be no expectation of difference in clinical course or outcomes for ongoing skilled nursing facility care versus a lower level of care.