Diagnosis: Dysphagia, Continuous positive airway pressure (CPAP) use at day, Mechanical ventilator use at night, Stage 4 sacral pressure ulcer.
Treatment: Continued Skilled Nursing Facility Services.
The insurer denied coverage for continued Skilled Nursing Facility Services.
The denial is overturned.

This is a female patient with multiple medical problems including hypertension, diabetes mellitus, and dysphagia. She was admitted to a Skilled Nursing Facility (SNF) and her treatment included nursing care, pulmonary specialist consultation, physical, occupational and respiratory therapies. Under review is the medical necessity for continued Skilled Nursing Facility (SNF) services for the time period under review.

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the patient has the medical acuity level and requires ongoing skilled nursing care that supports continued Skilled Nursing Facility (SNF) services for the time period under review.(1, 2, 3) The patient has multiple current clinical issues that require physician and nursing care, which are at least at the Skilled Nursing Facility (SNF) level of care. She has a Percutaneous Endoscopic Gastrostomy (PEG) tube, uses continuous positive airway pressure (CPAP) during the day and is mechanical ventilator dependent at night. She also has a stage 4 sacral pressure ulcer. During the time period under review, the treating physicians were in the process of weaning the patient from the mechanical ventilator at night, which further supports the medical necessity of continued Skilled Nursing Facility (SNF) services for the time period under review.

The healthcare plan has not acted reasonably, with sound medical judgment or in the best interest of the patient, Skilled Nursing Facility (SNF) services for the time period under review was medically necessary.

The carrier's denial of coverage for continued Skilled Nursing Facility Services is overturned.