Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Major Depressive Disorder.
Treatment: Long term Custodial Care.
The insurer denied Long term Custodial Care.
The determination is upheld.

The patient has a history of major depressive disorder, substance abuse, hepatitis C, asthma, and splenectomy. He was initially admitted to the hospital and treated for alcohol withdrawal with delirium tremens. He was discharged to subacute rehabilitation for mobility/gait / and activities of daily living dysfunction. The patient's liver function enzymes remained elevated and documented as asymptomatic from such. Therapy services were continued. A coronavirus (COVID)-19 antigen test was positive with a left basilar airspace density on the chest radiograph. Outpatient management was provided with resolution. The patient was afebrile and hemodynamically stable. A medication regimen was established. Liver function enzymes remained elevated and increased from the draw a month prior, but he was still asymptomatic. There was no change in management. Psychiatry evaluated the patient and did not document any acute or unstable conditions. Recommendations were to continue the established medication regimen and follow-up in 4-8 weeks. Physical medicine and rehabilitation (PM&R) followed up and documented that the patient was felt to have reached the highest practical functional level in a skilled rehabilitation program at this time. The patient was discharged from the skilled rehabilitation program. The patient was documented as stable and at baseline. Repeat liver function tests remained elevated but decreased from prior. The cardiologist followed up and documented the patient as stable from a cardiac standpoint. A referral to a hepatology clinic was performed. He was able to interact with staff appropriately and engage in independent activities. No acute issues or complications were documented during the dates of service in question. At issue is the medical necessity of long-term custodial care.

Based on the clinical documentation provided, evidence-based literature, and standards of care, custodial/long-term care was not medically necessary.
Hesselink et al. note hospitals have a responsibility to ensure that patients are discharged from hospital care safely and efficiently. This is becoming increasingly important, considering the trend towards shorter hospital stays and more care in the community, and the rising number of high-risk and elderly patients, who require more frequent and complex transitions. Despite the growing interest in the quality and safety of hospital discharge, research has shown that a variety of adverse events frequently occur in the handover of care, affecting patients after discharge from the hospital. In most cases, these adverse events could have been avoided. In addition, these adverse events in hospital discharge sometimes result in unnecessary readmissions and lead to a considerable amount of extra costs.[1]
In this particular situation, the patient was hospitalized and treated for a principal diagnosis of alcohol withdrawal with delirium tremens. He was assessed and felt to require continued care at a subacute rehabilitation for dysfunction of mobility/gait / and activities of daily living. He was discharged and admitted to subacute rehabilitation. Thereafter he was followed by an internist, cardiologist, psychiatrist, therapy services, and other members of the health care team. He had reached maximal benefit from the skilled rehabilitation program. He was established and maintained on a medication regimen. Psychiatry recommended follow-up in 1-2 months. Liver function enzymes were checked about every 3 weeks without significant changes and associated symptomatology. The patient was documented as able to identify and communicate needs, ambulate, and performed independent activities. No acute issues or complications requiring continued long-term care were documented. The patient met the criteria for discharge to the community. No acute medical or psychiatric issues were present, functional status was adequate for self-care support at a lower level of care, and medical comorbidities were managed at a lower level of care.[2]