Appeal type: Medical necessity
Decision: Upheld

Diagnosis: schizophrenia, chronic obstructive pulmonary disease, hyperlipidemia, essential hypertension, polysubstance abuse (alcohol, heroin and cocaine) and homelessness.
Treatment: Continued Skilled Nursing Facility 
The insurer denied the Continued Skilled Nursing Facility.
The denial is upheld. 

The patient has history that includes schizophrenia, chronic obstructive pulmonary disease, hyperlipidemia, essential hypertension, polysubstance abuse (alcohol, heroin and cocaine) and homelessness.  He has been residing in a men's shelter.  He is in a community methadone maintenance treatment program.  He is generally independent at baseline, using a Rollator walker.  He does receive unspecified assistance from "acquaintances in [his] shelter."

The patient was admitted to the hospital following two reported falls with head strike.  He had reportedly been riding on a bus when he slipped while walking off the ramp, hitting his head, without loss of consciousness.  Later, while sitting on a bench, he reportedly dozed off and hit his head again.  He was diagnosed with acute metabolic encephalopathy.  There is no further pertinent documentation related to his medical evaluation or medical treatment during this hospitalization.

An inpatient physical therapy evaluation noted that the patient had an unsteady, wide-based gait with difficulty changing directions.  He required min assist to ambulate 30 feet with a Rollator.  Admission at a subacute rehabilitation facility was recommended to maximize independence and safety.

The patient was transferred to a subacute inpatient rehabilitation facility for further care.  His history was also noted to include glaucoma, prediabetes and chronic right hip pain.

The patient was noted to have 3-/5 bilateral upper limb strength.  He was contact guard to min assist for most self-care, including toileting, bathing, dressing and hygiene/grooming.  He was supervision for feeding.  He was mod assist for propelling a wheelchair 30 feet.  He was contact guard assist for transfers.  He was ambulating 20 feet at mod assist.

The patient was transferring independently.  He was ambulating 250 feet at modified independence.  He was independent with wheelchair mobility.

The patient was noted to have 4+/5 bilateral upper limb strength.  He was independent with toileting, bathing, dressing, hygiene/grooming, feeding and wheelchair mobility.  He was discharged from occupational therapy.

The patient was independent with transfers and mobility for "unlimited distances" with a walker, with breaks for rest due to chronic right hip pain.  He was discharged from physical therapy.

Social worker notes indicated that the patient would be returning to the community when fully independent.  It was noted that he did not have custodial coverage benefits.  There were communications between the facility and the patient's shelter. 

The patient was discharged back to his shelter.

No, the inpatient services from were not medically necessary at the skilled nursing facility level of care.

The patient had chronic medical conditions and chronic functional impairments.  He had chronic hip pains.  Although generally independent at baseline, he was using a Rollator walker and receiving unspecified assistance from his shelter-mates.

The patient was hospitalized after falls with head strikes, but there is no documentation of any new, significant intracranial pathology or intervention.  Within a few days of hospitalization, he was transferred to a facility for further care.  The patient was independent with mobility.  He was independent with his self-care.  He had been discharged from formal therapy services.

The available records do not indicate that there were any inpatient medical, nursing or therapy needs.  The records do not indicate that the stay during this time was needed for any reasons other than custodial needs while he was administratively being transitioned back to his homeless shelter.  Skilled nursing facility level of care during this time was not medically necessary.