Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Traumatic amputations of the first and second
rays of the right hand
Treatment: Continued Stay Skilled Nursing Facility
The insurer denied the Continued Stay Skilled Nursing Facility
The denial is upheld.

The records report that the health plan member is a female with a history of traumatic amputations of the first and second rays of the right hand due to unspecified circumstances on an unspecified date.  Her prior functional status was independent and living with her brother in the community.  The brother, however, was/is in the process of moving out of the country.  She was working as a self-employed interior designer.  She had no medical issues prior to the partial hand amputation and reportedly had not seen a doctor for many years.

Earlier this year, the patient underwent reimplantation of the amputated digits.  Postoperatively, she developed bilateral foot drop, bilateral upper extremity paresthesias, distal left upper limb weakness and difficulty with walking.  She was diagnosed with mononeuritis multiplex.  She ambulated using bilateral posterior leaf spring ankle foot orthoses without a gait assistive device.  Her course was further complicated by right hand osteomyelitis at the traumatic injury site.  She underwent right upper extremity debridement, not further specified.  She received antibiotics.

The patient was transferred to a skilled nursing facility from the hospital for further care.  The principal diagnosis was right hand osteomyelitis.  Past medical history included depression.  She was not on supplemental oxygen.  She was continent of bowel and bladder.  On examination, she was cognitively intact.  She had a thermoplastic right upper extremity splint.  There was right upper extremity edema.  She was moving all extremities, with limitations at the right elbow due to her splint.  Detailed examination of the right hand was documented in the available records.  She had weakness in both legs.  There was no edema in the legs.  There was a right thigh skin donor site.  Her wound care for the right upper extremity wound was hydrofiber with ionic silver dressing (Aquacel AG) and circumferential gauze.  She was to have weekly lab tests drawn, with results sent to the infectious disease consultant.  She had right upper limb non-weightbearing restrictions.  On therapy evaluations, she was requiring moderate assistance for toileting, bathing and dressing.  She was independent with transfers and set up for walking 150 feet with bilateral ankle foot orthoses.

The health plan denied coverage at the facility for the last five days of service and forward as it deemed that the patient's care needs could have been met in the community setting and permanent long-term care was not medically necessary.

No, the proposed treatment is not medically necessary.
The patient was admitted to the skilled nursing facility primarily with issues affecting her right hand and right upper extremity.  She had mild impairments affecting her lower limbs.  At the time of her initial therapy evaluations she was already independent for transfers and set up for ambulating household distances with her ankle foot orthoses.  The patient was set up for upper body dressing, supervision for toileting and minimum assistance for lower body dressing.  She essentially plateaued functionally at that point, continuing to require some physical help on an intermittent basis for some of her self-care activities.  Sufficient home care for the patient to reintegrate back to the community was set up, but the patient declined this arrangement, stating a preference for her brother to help her after he arrives from out of town.  The continued stay at the facility for the last five days in question was not necessary as her care could have been provided in the community with custodial level assistance on an intermittent basis.  There were no therapy, nursing, medical or other needs for her to remain in an institutional setting.

As discussed above, the patient could have reintegrated to the community with assistance.  This assistance had been arranged and was available.  The denial of coverage by the health plan was appropriate given that the care in question was not medically necessary for the patient.