The patient is a male with past medical history of diabetes mellitus, hypertension, alcohol abuse, asthma and liver cirrhosis who was admitted to skilled nursing facility following hospitalization secondary to cerebrovascular accident (CVA) and acute respiratory failure.

The health plan's determination is upheld.

The patient is a male who suffered a CVA. At time of admission to skilled nursing, he was dependent with bed mobility, transfers and unable to ambulate. In two months the patient was only able to progress to moderate assistance with bed mobility and transfers and both these functions remained at moderate assistance (MODA). In addition, while he did ambulate 10' maximum assistance (MAXA) this slow progress took over 2 months and MAXA (with assistance for weight shifting and walker management in the addition to a wheelchair follow) is not functional. Furthermore, wheelchair propulsion only progressed from dependent, to MAXA and the goal itself was discontinued. Hygiene/grooming also remained at MAXA from admission through discharge and toilet transfers remained dependent when goal was discontinued. Upper body dressing only improved from dependent to MAXA and remained MAXA and upper body bathing remained dependent when goal was discontinued. Review of documentation also showed that the patient was tolerating percutaneous endoscopic gastrostomy (PEG) tube feedings and was not requiring any skilled management of intravenous (IV) medications and/or extensive wound care. Therefore, as functional progress had not been made since admission over two months prior it was no longer appropriate nor medically necessary for this patient to continue at a skilled nursing level and his needs could be met at a lower level of care.

No, the requested health service of skilled nursing facility is not medically necessary for this patient. The patient was admitted to skilled nursing but review of therapy documentation failed to show functional progress with the most progression being progress to MODA for transfers and bed mobility and this required over 2 months to achieve. Additionally, review of records fail to show skilled nursing needs such as IV medication or extensive wound care. It is not within recommended standards of care to remain at a skilled level of care when functional progress is unlikely to occur in a reasonable amount of time.