Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left lower leg pain

Treatment: continued stay in a skilled nursing facility (SNF)

The insurer denied coverage for a continued stay in a skilled nursing facility
The denial is upheld

This is a male who has left lower leg pain. Past medical history includes hypertension, hyperlipidemia, polysubstance abuse, schizoaffective disorder, and bipolar disorder. Prior treatment history includes medication, physical therapy, and occupational therapy. Physical exam on the most recent report is not documented. Diagnostic imaging is not documented. Documented diagnoses are essential hypertension, unspecified dementia without behavioral disturbance, dysphagia unspecified, other abnormalities of gait and mobility, difficulty in walking, not elsewhere classified, and muscle weakness. The information provided is inadequate to support the appeal.

Werner, R. M., Coe, N. B., Qi, M., & Konetzka, R. T. (2019), "Results: A total of 17, 235, 854 hospitalizations (62.2% women and 37.8% men; mean [SD (standard deviation)] age, 80.5 [7.9] years) were discharged either to home with home health care (38.8%) or to a skilled nursing facility (61.2%) during the study period. Discharge to home was associated with a 5.6-percentage point higher rate of readmission at 30 days compared with discharge to a skilled nursing facility (95% CI (confidence interval), 0.8-10.3; P (probability) = .02). There were no significant differences in 30-day mortality rates (-2.0 percentage points; 95% CI, 0.8-10.3; P = .12) or improved functional status (-1.9 percentage points; 95% CI, -12.0 to 8.2; P = .71)."

Per Hakkarainen, T. W., Arbabi, S., Willis, M. M., Davidson, G. H., & Flum, D. R. (2016), "Of 416,997 patients, 3.8% died during the initial SNF stay, 28.6% required readmission, and 60.5% were ultimately discharged home. Readmission to a hospital was the strongest predictor of death in the years after SNF admission (unadjusted hazard ratio, 28.2; 95% confidence interval, 27.229.3; P < 0.001). Among all patients discharged to SNFs, 7.8% eventually died in an SNF and overall, 1-year mortality was 26.1%. Risk factors associated with mortality and failure to return home were increasing age, male sex, increasing comorbidities, decreased cognitive function, decreased functional status, parenteral nutrition, and pressure ulcers."

Per Goodwin, J. S., Li, S., Middleton, A., Ottenbacher, K., & Kuo, Y. F. (2018), "Within 6 months of SNF admission, 10.4% of participants resided in LTC (long term care). After adjustments for participant characteristics, the SNF where a participant received care explained 7.9% of the variance in risk of LTC [long term care], whereas the prior hospital explained 1.0%. Individuals in SNFs with excellent quality ratings had 22% lower odds of transitioning to LTC than those in SNFs with poor ratings (odds ratio=0.78, 95% confidence interval=0.740.84). Variation between SNFs and associations with quality markers were greater in sensitivity analyses limited to individuals least likely to require LTC. Results were essentially the same in a number of other sensitivity analyses designed to reduce potential confounding."                                                         

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for a continued stay in a skilled nursing facility is upheld. Medical Necessity is not substantiated.