Diagnosis: Respiratory System/Pneumonia
Treatment: Inpatient Hospital
The health plan denied the requested acute care facility admission as not medically necessary.
The health plan's determination is overturned.

This is a male who contracted COVID 19 pneumonia, eventually leading to respiratory failure requiring prolonged mechanical ventilation and tracheostomy. He was eventually liberated from the ventilator and discharged to a skilled nursing facility. He presented to the Emergency Room again for worsening respiratory distress and again needed to be placed on a ventilator. He has required ventilatory support since several months ago with ongoing pressure support trials during the day. This hospitalization has been complicated by pneumothoraces requiring chest tubes, pneumonia with multi-drug resistant organisms, and a decubitus ulcer that has led to osteomyelitis. A long-term acute care (LTAC) admission is being requested for ventilator weaning, intravenous antibiotics, and wound care.

I overturn, in whole, the health plan's determination of medical necessity.

Yes, the LTAC admission is medically necessary for this patient. The patient has now been on the ventilator since admission. He has a tracheostomy that is in place. All underlying processes have been stabilized. His pneumothoraces have been addressed with chest tubes. His infections have been addressed with appropriate and ongoing antibiotic courses. He is ventilator dependent currently but is making attempts at weaning and he seems to have some spontaneous breathing with adequate inspiratory effort. He is otherwise hemodynamically and neurologically stable, but does require daily nursing, respiratory therapy, and physician services.

This is a patient who is best suited for long term acute care. All acute processes have been stabilized. However, he still requires acute care for his ventilator weaning and wound care for his decubitus ulcer.