Diagnosis: Gangrene and osteomyelitis

Treatment: Skilled Nursing Facility Stay

The insurer denied the Skilled Nursing Facility Stay. The denial was upheld.

This is a male patient with a history of traumatic brain injury (TBI), alcohol dependence and seizures. He presented to the hospital for surgical amputation of his right digits 1-3 and left foot digit 1 due to gangrene and osteomyelitis. He was admitted to a skilled nursing facility for post- operative wound care and rehabilitation.

Continued skilled nursing facility (SNF) level of care after several weeks was no longer medically necessary due to the patient's improved functional ability. He also did not require complex wound care. According to a nursing note dated at that time, the patient was independently ambulating without the use of a device. Wound care was routine and on several occasions, the patient actually refused treatment. There are no specific complex nursing needs or acute medical issues that required ongoing inpatient skilled nursing or medical services. The patient could have been safely transferred to a lower level of care. From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the continued SNF stay was no longer medically necessary. The insurer acted reasonably, with sound medical judgment, and in the best interest of the patient.

The insurer acted reasonably, with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the continued skilled nursing facility is not substantiated. The insurer's denial is upheld.