Diagnosis: Asthma, hypertension, hypothyroidism, and peripheral neuropathy

Treatment admission to a Skilled Nursing Facility for subacute rehabilitation services

The insurer denied coverage for admission to a Skilled Nursing Facility for subacute rehabilitation services

The denial is upheld

This is the case of an adult male patient with chronic medical problems including asthma, hypertension, hypothyroidism, and peripheral neuropathy. He was admitted to the hospital for evaluation and treatment of progressive weakness, altered mental status and weight loss over the past several months. Under review is the medical necessity for requested admission to a skilled nursing facility (SNF) for subacute rehabilitation services.

Based on the clinical records made available for review, the patient is not an appropriate candidate for subacute rehabilitation at a SNF (1, 2, 3). His reported symptoms have gradually progressed over the past year. The patient lives at home under the care of his spouse and home health aide. He has been in the hospital for well over a month. Of particular note is the limited physical and occupational therapy services provided; specifically, while awaiting SNF placement. Only one week of occupational and physical therapy notes made available for review, respectively, documenting a level of function at essentially the minimal assistance level. Subsequent physical and occupational therapy notes were not included for review. Given the chronic nature of his condition and pre-hospital level of care; returning home under the care of spouse and home health aide with home physical therapy is the most appropriate level of care for this patient at this time.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based).

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, admission to a SNF for subacute rehabilitation services is not medically necessary.

The insurer's denial of coverage for the requested admission to a Skilled Nursing Facility for subacute rehabilitation services is upheld. Medical necessity is not substantiated