Diagnosis: Sepsis, cerebral infarct, diabetes mellitus and congestive heart failure

Treatment: Alternate level of care in a skilled nursing facility

The insurer denied alternate level of care in a skilled nursing facility. That denial was reversed

This patient was admitted to an extended care facility for rehabilitation. Currently under review is the medical necessity for continued alternate level of care in a Skilled Nursing Facility (SNF).

The clinical records demonstrated gradual functional progress that supported continued alternate level of care in a Skilled Nursing Facility (SNF). For the time period under review, the patient demonstrated functional improvement for ambulation, dressing and transfer activities that ranged from minimal assistance to functional independence. The additional approximately 2 weeks of therapy allowed the patient to meet discharge goals (for functional mobility and activities of daily living) with the ability to return home.

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the requested coverage for the alternate level of care in a skilled nursing facility was medically necessary.