Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services. Findings:  The physician reviewer found that patients with multiple sclerosis have relapsing-remitting disease, but some patients transition to a secondary progressive disease with less frequent relapses over time (Ontaneda; Baldassari and Fox). There are multiple disease modifying therapies that target the inflammatory processes associated with multiple sclerosis that can be moderately to highly efficacious. There are fewer treatment options for the neurodegenerative component of progressive multiple sclerosis. Treatment is otherwise largely supportive, focused on ameliorating symptoms, and related to restoring or optimizing function in the setting of exacerbations or progressive disease with reconditioning and compensatory interventions. This patients records support progressive multiple sclerosis with deteriorating function. He is on interferon beta-1a therapy to address the autoimmune inflammatory component of his disease. The patient has been experiencing frequent falls at home despite use of a walker. His functional impairments are complicated by the challenges of obesity. The patient was not a safe and functional ambulator at baseline prior to his right wrist fracture. He has exhibited acute on chronic decline in his function due to a right wrist fracture while attempting a basic task at home, but the records do not demonstrate that he had a multiple sclerosis relapse. As of the date of denial, the patient had undergone about two weeks of inpatient rehabilitation following his nonoperatively addressed right wrist fracture. The provider noted that the patient made significant progress with respect to his function and he managed to improve to contact guard to stand by assistance for transfers and minimum assistance for ambulating household distances with a walker with a right platform attachment. By the date of denial, the patient had reached the maximal practical level of function expected for his condition, comorbidities, and impairments. The patient is not expected to make any further clinically meaningful progress until the right wrist heals further to the point that he can bear full weight. The patients longer-term progress is guarded given the progressive nature of his condition and his baseline level of function in the community. The records support that the patient has been at a custodial level of care, and he is not a candidate for continuing services at a SNF level of care. Given these findings, the SNF services were not and are not medically necessary for treatment of this patient.  Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.