Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical myelopathy
Treatment: Skilled Nursing Facility, Pre-service
The insurer denied the Skilled Nursing Facility, Pre-service.
The denial is upheld.

The patient is a female with history of falls and found to have cervical myelopathy and also sustained a left radial fracture status post reduction and casting. She is status post C4 corpectomy.  The patient has a relevant past medical history of liver cirrhosis, portal hypertension, chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD), hypertension, diabetes mellitus, hepatitis A, hyperlipidemia, renal insufficiency, etc.

The patient was admitted to acute inpatient rehabilitation with safety fall precautions and non-weight bearing (NWB) of the left upper extremity.  

The reason for prior the denial of transfer to Skilled Nursing Facility (SNF) was her ability to ambulate 400 feet and therefore it was not medically necessary.  The appeal is to enable her transfer to the Skilled Nursing Facility (SNF).

Prior to admission, the patient was independent using a four-wheeled walker and lived alone in an apartment with elevator and no steps to navigate. She has social support from her children and grandchildren. She has a Home Health Aid seven days a week of which four days are four hours per day and the other three days are seven hours per day.

The patient was ambulating with contact-guard 150 feet without assistive device, was non-weight-bearing of the left upper extremity, has a hard-collar, required supervision for pivot transfers, required supervision-minimal assistance with most activities of daily living while independent for sitting static balance, contact guard for standing static balance and minimal assistance for dynamic balance.  She required maximum assistance for bathing and putting on shoes and socks.

No, the Skilled Nursing Facility (SNF) is not medically necessary.

The patient was admitted to acute inpatient rehabilitation.

As stated above, Skilled Nursing Facility (SNF) is not medically necessary with clinical evidence as stated above showing level of improvement that further stay in the Skilled Nursing Facility (SNF) is not reasonably expected to be health beneficial for the patient and/or withholding it in whole or in part to be reasonably expected to affect the patient's health adversely as the patient's needs can be met at a lower level of care.
She was ambulating with contact-guard 150 feet without assistive device, was non-weight-bearing left upper extremity, had a hard-collar, required supervision for pivot transfers, required supervision-minimal assistance with most activities of daily living while independent for sitting static balance, contact guard for standing static balance and minimal assistance for dynamic balance.  She required maximum assistance for bathing and putting on shoes and socks.

The request for rehabilitation in Skilled Nursing Facility (SNF) stay is stated to improve on her balance and decrease the risk of falls before discharge but her static and dynamic balance were shown to be adequate as stated above. Further rehabilitation goals can be met with home therapy and continued assistance with home health aide (HHA).