Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Below knee amputation

Treatment: continued skilled nursing facility subacute rehabilitation level 1 services

The insurer denied coverage for continued skilled nursing facility subacute rehabilitation level 1 services

The denial is upheld
 

The patient had been at the hospital for diagnoses of infection of stump, cellulitis (methicillin resistant staphylococcus aureus (MRSA)), status post stump revision, uncontrolled diabetes, peripheral artery disease, and alcohol abuse. The physiatry consultation exam noted integumentary-right great toe and second toe amputated right third toe and skin opening at the top of the toe 2 x 2 centimeters (cm).  The patient had a below knee amputation status post revision with 11 sutures with slight drainage noted.  There was partial healing with slight dark discoloration to site. The patient had difficulty with ambulation and activities of daily living.  

The Milliman Care Guidelines (MCG) note that inpatient rehabilitation is indicated when intense and complex care needs make inpatient care safer and more practical than attempting care at a lower level.  The patient's status should support active participation in, and benefit from, intensive rehabilitation skilled care.  There should be goals for measurable improvement.  There should be involvement of an interdisciplinary team with in-person physician assessment and monitoring at least 3 days per week (days/week).  The documentation should identify that multidisciplinary therapy services are needed and that skilled nursing services are needed.

In this case, the patient participated in skilled nursing facility level of care with noted improvement with occupational and physical therapy.  The patient had met multiple goals as of but continued to have functional deficits.  Continuation of skilled nursing facility level I of care was recommended.  However, the documentation did not support that the patient's care needs were intense and complex to require inpatient care over outpatient treatment. The patient had made significant progress with inpatient therapy.  The patient met goals for self-feeding independence.  The patient met goals for independence for hygiene/grooming.  The patient had met goals for bed mobility.  The patient only required supervised assistance with transfers and had improvement in lower body strength.  The patient was able to ambulate short distances without hands-on assistance.  The documentation did not support severity of functional deficits that continued to require an inpatient level of care.  While it was noted that skilled nursing provided medication management and monitoring with dressing changes of the surgical site, the documentation did not reveal that the patient had cognitive or physical impairments that precluded their ability to manage medications and dress the stump site.  Therefore, the patient was appropriate for a lower level of care with home care and outpatient management.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for continued skilled nursing facility subacute rehabilitation level 1 services is not substantiated.