Orthopedic
Skilled Nursing Facility

Diagnosis: Femoral and patella fracture
Treatment: Sub-acute rehabilitation
The insurer denied sub-acute rehabilitation.
The health plan's determination is upheld.

The patient is a female who suffered a traumatic femoral and patella fracture requiring open reduction internal fixation (ORIF) of right distal femur fx (fracture). Post-operatively, the patient was admitted to skilled nursing facility. The patient requested approval for continued rehabilitation stay.

The sub-acute rehabilitation is not medically necessary. The patient was admitted to skilled nursing facility for post-acute rehabilitation following hospital course related to acute traumatic femoral and patella fracture status/post (s/p) ORIF right distal femur. At time of initial evaluation, she required moderate assistance (MODA) for bed mobility, transfers and ambulation of 5' with wheeled walker (WW). She was non-weight bearing (NWB) to her right lower extremity (RLE). Documentation noted that she lived in a 3rd floor apartment with steps to manage. Review of documentation noted that she made excellent progress and she had good static standing, ambulated 275' with WW modified independent (MODI) and was able to ascend and descend 12 steps with contact guard assist (CGA).

Documentation also noted that she was modified independent with meal prep/clean up and bed making. She also required set-up for car transfers. This level is appropriate for discharge to a lower level of care. Additionally, while therapy discharge did note some additional progress this level of progress was not required to discharge to a lower level of care and could have been met with outside therapy services. For example, therapy stated patient ambulated 100' without an AD (assistive device) independently, but the patient was already ambulated 275' with a WW MODI. Steps did improve to supervision, but steps alone is not reason to keep a patient at this level of care. Lastly, the documentation did not support that the patient was not medically stable for last covered day. Despite reports of an eye infection, this is not a diagnosis nor treatment regimen that requires skilled nursing care. Additionally, it was documented that the patient reported new right hip/thigh pain and an x-ray was ordered yet there was no follow-up documentation regarding such pain, leading this reviewer to opine the patient was medically stable. Additionally, right hip pain alone does not support continued rehab stay, especially since the physical exam did not even include a musculoskeletal component.