Diagnosis: Traumatic brain injury

Treatment: Continued skilled nursing care

The insurer denied coverage for continued skilled nursing care.

The denial is upheld.

This is a male patient who sustained a traumatic brain injury in the past with resultant left subdural hematoma and status post hemi-craniectomy. The patient also required tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placement. The patient underwent a cranioplasty and was transferred to a skilled nursing facility (SNF) for subacute rehabilitation. The patient was transferred back to the acute hospital for seizures and subsequently readmitted to the SNF. Under review is the medical necessity for continue skilled nursing care on or after day 14 of re-admission.

The clinical records demonstrate a level of physical impairment that supported the medical necessity for trial subacute rehabilitation services at the SNF. However, on and after day 14 of re-admission, the treatment notes do not document any substantial improvement for the patient. For example, according to the physical therapy notes, the patient remained totally dependent for functional mobility (including bed mobility and transfer activities). A similar level of dependence and lack of improvement was documented by the occupational therapist. The patient remained at the total assistance level for activities of daily living. There were no specific acute medical problems or complicated nursing issues preventing the patient's safe discharge to a lower level care effective on or after day 14 of re-admission.

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, continued skilled nursing care on or after day 14 of re-admission was not medically necessary.

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

The carrier's denial of coverage for continued skilled nursing care should be upheld. The medical necessity is not substantiated.