Diagnosis: s/p (status post) Stroke.
Treatment: Admission to Skilled Nursing Facility.

The insurer denied the admission to Skilled Nursing Facility. The denial is upheld.

The patient is a female who suffered a massive subarachnoid and intraventricular hemorrhage secondary to a middle cerebral artery aneurysm. She initially did not progress with rehab and was discharged home. Since that time, she has made neurologic recovery with therapy provided and is more cognitively capable of participating in therapy.

Admission to the SNF (skilled nursing facility) was requested. It was initially denied as not medically necessary. This is the subject of the appeal.

No, the requested admission to skilled nursing facility is not medically necessary.
The patient suffered a hemorrhagic stroke and has continued neurologic deficits and functional impairments. She is receiving therapy in the home. She continues to require maximal assistance with bed mobility and total assistance with transfers. Standard of care for admission to SNF (skilled nursing facility) is the need for daily skilled rehabilitation or skilled nursing services. At this point in her recovery, her care would be considered custodial. Further significant improvement in a reasonable and predictable period of time is not expected. Admission to the SNF (skilled nursing facility) for rehabilitation is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The admission to the skilled nursing facility would not be considered reasonable and necessary due to the patient's ongoing deficits and lack of improvement with prior therapy. The denial was reasonable.