Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pelvic chondrosarcoma
Treatment: Continued Skilled Nursing Facility
The insurer denied: Continued Skilled Nursing Facility
The denial is upheld.

The patient is an adult female with a history of a left hemipelvectomy for pelvic chondrosarcoma. She had a complicated postoperative course. She underwent wound debridement and vacuum-assisted closure dressing placement. She underwent rectal perforation repair and diverting colostomy. Subsequently, she underwent multiple washouts and partial closure surgeries. A drain was placed on for the abdominal collections. She also underwent incision and drainage of an abscess.

The patient was transferred to a skilled nursing facility for further care. She was on a regular consistency oral diet. She had an indwelling urinary catheter and colostomy. She had a vacuum-assisted closure dressing. She was requiring a Hoyer lift for transfers with nursing. On therapy evaluations, she was dependent for transfers, moderate assist for upper body bathing, moderate assist for upper body dressing, maximum assist for lower body bathing, maximum assist for lower body dressing.

On day 32, the patient completed intravenous antibiotics. As of day 39, the patient was set up for grooming, supervision for upper body dressing, and total assist for lower body dressing.
As of day 44, the patient's vacuum-assisted closure dressing was discontinued.
On day 45, the patient's indwelling urinary catheter was removed. She was subsequently voiding urine incontinently.
As of 46, the patient was set up for grooming, supervision for upper body dressing, and total assist for lower body dressing.
On day 47, antibiotics were started for a urinary tract infection. Blood cultures were drawn and subsequently negative.
As of day 53, the patient was dependent for transfers. She was non-ambulatory. She was dependent for wheelchair mobility and management. Her wounds were being packed with gauze twice a day.
The health plan denied coverage of the service under review, indicating that the service is not necessary because the patient was not making progress with therapy. She needed a lot of help to bathe. She needed total help for transfers. She was unable to ambulate. The denial is being appealed.

The continued skilled nursing facility stay was/is not medically necessary.

The patient had plateaued with respect to function, where she was essentially at a set-up to supervision level for her upper body activities and totally dependent for all lower body activities, transfers, and mobility. There were no indications that she was self-propelling or otherwise operating a wheelchair, hopping using a walker, or doing other activities expected for a person with the patient's conditions, including a hemipelvectomy. There was no need for ongoing rehabilitation on and after day number 53 based on her functional course to date. The patient was not making any documented progress with respect to self-management of her urinary management, e.g., management of the indwelling urinary catheter, or her colostomy. She 
had a persistent postoperative wound with stable wound care needs that could have been provided in a less intensive setting. Medically, she was stable with needs that could have been met in the community and ambulatory setting. She was stable on an oral diet. Vital signs and laboratory test results were stable. Pain was manageable on oral analgesics. She was not receiving intravenous antibiotics or any other therapy that required or would have been best administered in the inpatient/facility setting.
Overall, the patient was receiving maintenance/custodial care. The ongoing skilled nursing facility days in question was/is not medically necessary.