Diagnosis: S/p (status post) COVID-19 infection.
Treatment: Long-term custodial care, pre-service.
The insurer denied the long-term custodial care.
The denial is overturned.

The patient is a female with history of confusion and general debility with abnormal gait, decreased balance and ambulation after COVID-19 (coronavirus) infection. She has relevant history of depression, Alzheimer's disease, hypertension, hypothyroidism, ulcerative colitis, etc.

The patient is unable to follow commands due to her state of confusion, but she is participating in therapy.

Prior to admission, the patient lived with her husband in an apartment building with elevators. She had HHA (home health aide) Monday to Friday for 5-6 hours per day, and she was using rolling walker for ambulation. Her husband is unable to help in her ADLs (activities of daily living).

The patient requires maximum assistance for most ADLs.

Transfer to a nursing facility for long-term custodial facility was denied by the health plan due to lack of enough clinical information, with an appeal providing further clinical information.

Yes, the long-term custodial care is medically necessary.

Post-Covid infection, the patient has general debility, gait imbalance, ambulation difficulty and confusion while requiring maximum assistance for most ADLs.

The patient needs to be in a long-term custodial care, because she needs help with daily living activities including eating, which has led to loss of weight, dressing, bathing, transferring and ambulating, while requiring rehabilitation in OT (occupational therapy) and PT (physical therapy) for the purpose of improving function to an extent that might allow for a more independent existence.

As noted above, the transfer to a long-term custodial care is medically necessary with clinical evidence of general debility and decreased ADLs associated with confusion.

The patient will not be able to achieve any tangible improvement in a lower level of care, such as outpatient rehabilitation or home rehabilitation.