Diagnosis: Type 2 diabetes mellitus, hyperlipidemia, prostate cancer, and acute hypoxic respiratory failure and encephalopathy, secondary to COVID19 (2019 Novel Coronavirus) pneumonia

Treatment: skilled nursing facility (SNF) long-term custodial care

The insurer denied coverage for skilled nursing facility (SNF) long-term custodial care

The denial is overturned.

The patient has multiple medical problems including diabetes mellitus and prostate cancer. He developed acute respiratory failure and encephalopathy due to COVID pneumonia. He received care at an SNF (including physical and occupational therapy). Under review is the medical necessity of skilled nursing facility (SNF) long term custodial care.

The insurer indicated the criteria for approval were not met as they did not receive completed necessary forms indicating need for "permanent placement" at a nursing facility, or documentation indicating that the patient/family agreed to a permanent placement plan. However, the generally accepted clinical criteria indicate patients require either hands on assistance with activities of daily living (ADLs)/mobility or cognitive deficits with supervision/cueing for ADLs. His cognitive deficits had resolved prior to admission to the skilled nursing facility (SNF). For the time under review, the patient required assistance for activities of daily living, including dressing and toileting. He also required assistance for transfer activities and ambulation. He made an excellent functional recovery and was appropriately discharged.

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical probability, the skilled nursing facility (SNF) long term custodial care was medically necessary.

The insurer's denial of coverage for skilled nursing facility (SNF) long-term custodial care is reversed. Medical necessity is substantiated.