Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Polytraumatic injuries. 
Treatment: Continued skilled nursing facility stay. 
The insurer denied the Continued skilled nursing facility stay. 
The denial is upheld. 

The patient is a male. The patient is reported to have a history of polytraumatic injuries due to having fallen onto the subway tracks "during drug induced psychosis" and having been struck by a train. 

The patient underwent bilateral below knee amputations. He underwent ORIF (open reduction internal fixation) surgery of a right distal radius fracture. Other injuries were noted to include a left manubrium of sternum fracture, left rib fractures and a T1 (first thoracic spine vertebra) spinal fracture. His disposition between his initial hospitalization is unclear. 

The patient was rehospitalized at his original acute hospital for unspecified reasons. 
	
The patient was transferred to a skilled nursing facility for further care. He was noted to be alert, oriented and able to make his needs known. He was on a regular diet without restrictions. He was continent of bowel and bladder. He had a small open surgical site on the left lower limb being cleansed with Dakin's solution and covered with nonadherent dressings. It was noted that his baseline was living in and out of homeless shelters. His plan was to return to a shelter once his rehabilitation is complete. 

On examination by the physician's assistant, the patient was noted to have no pains. He was on gabapentin, Tylenol as needed, and cyclobenzaprine as needed. He was also on Zyprexa. The plan was in-house mental health provider follow-up and gradual taper of Zyprexa. Nursing noted that there was 100% granulation tissue at his left lower limb wound, with no signs of infection. 

Psychiatry noted that there was a history of amphetamine use disorder and possible schizoaffective disorder. A reduction in Zyprexa was planned. 

The patient was subsequently regularly followed by various mental health providers. His Zyprexa was weaned. Mood and behavior were stable, with occasional depression and mild anxiety. Social withdrawal improved. He remained cognitively intact. His wound was treated and noted to improve. 

It was noted that the patient is homeless. He was doing prosthetic rehabilitation with therapists. The plan was discharge to assisted living if he is able to do his activities of daily living by himself "after completion of prosthetic training." 

The patient was noted to have no recent mood or behavioral changes. He had a splint in his right hand. No swelling or discoloration of the bilateral lower limbs was noted. 

On a care plan meeting with the patient and his family, it was noted that he was clinically stable. He wished to go to assisted living but lacked the income. His Social Security application was in process. Disposition options were discussed. He did not want to go to his sister's home. 

It was noted that the patient was resting from prosthetic training due to a wound at the bottom of his left lower limb. 

No, the Continued skilled nursing facility stay is not medically necessary. 

The standard of care for postamputation rehabilitation begins with healing and gradual shaping of the residual limb, aimed towards the eventual fitting of a prosthesis. Preprosthetic therapy is applied, to include prevention of contractures, balancing activities and maintaining/improving cardiovascular and musculoskeletal conditioning. Improved mobility and function are generally pursued by hopping on one leg with a walker for unilateral lower limb amputees, or at a wheelchair level for bilateral lower limb amputees, if appropriate. 

A temporary prosthesis is typically fashioned to begin initial weightbearing once the residual limb is sufficiently healed. Prosthetic fitment typically commences no earlier than approximately six to eight weeks post amputation. Gradually, the time spent wearing the prosthesis is increased until it can be worn all day, a process that can take several weeks to months. Notably, as more time is spent wearing the prosthesis and practicing short bouts of ambulation, the residual limb's shape further matures, which can require adjustments to the prosthesis, potentially lengthening the process further.  Eventually, if proper fitment can be achieved and the tissues become sufficiently conditioned for greater physical demands, the user can wear and use the prosthesis for all-day community level ambulation, as long as their cardiovascular conditioning level will allow this. 

The prosthetic rehabilitative process, overall, can take many months, if not a year or two or longer, after a prosthesis is first worn. Persons experiencing new bilateral lower limb amputations can be expected to have an even more protracted and challenging course. There should be no expectation of community-level independence using prostheses for ambulation following an initial hospitalization and rehabilitation course after major trauma and lower limb amputations. In the interim, as prosthetic rehabilitation is pursued, full functional restoration in the absence of a prosthesis needs to be concomitantly pursued and achieved. Persons initially hospitalized with new major lower limb amputation(s) can return to the community when their functional status without a prosthesis permits. Prosthetic rehabilitation can be and is generally pursued in large part in the community due to the prolonged duration of time that is required. 

In the present case, the patient has sustained bilateral traumatic lower limb amputations. He was approximately five months post amputations. His residual limbs had not fully healed, but they had healed sufficiently for prosthetic training and ongoing care outside of an institutional setting. There were no active medical or skilled nursing needs requiring ongoing inpatient level care at a skilled nursing facility. There were no documented rehabilitative interventions that could not have been pursued in a community setting. Notably, he has been homeless and remains homeless. He has declined to go to his family patient's residence. His care could otherwise be pursued in the community with community-based services, appropriate durable medical equipment (e.g. [exempli gratia], a wheelchair), and caregiver support. The patient's stay has been custodial and not medically necessary at the skilled nursing facility level of care.