Diagnosis: Endocrine/Metabolic/Nutritional-Diabetes.
Treatment: Skilled Nursing Facility-Nursing home services (long term care).

The health plan denied Nursing home services (long term care) as not medically necessary.
The reviewer has upheld in whole the health plan's determination.

The patient has a past medical history significant for diabetes. He was admitted secondary to acute mental status changes secondary to hypoglycemia and hypothermia. Patient was admitted after an acute hospital stay. History is significant for diabetes, hypertension, and history of peripheral vascular disease with left above-the-knee amputation. This review is for medical necessity of ongoing long term care. Services were denied as not medically necessary.

Ongoing Nursing home services (long term care) is not medically necessary. The patient can ambulate, transfer, dress, and toilet independently. Care could be provided in an alternate location. Patient was admitted after an acute hospital stay. He has a history of diabetes mellitus with a left above the knee amputation. He was admitted with decreased muscle strength, balance abnormality, decreased activity tolerance and a decline in functional mobility. He was admitted for skilled physical therapy and occupational therapy services. He can use his prosthesis independently.
The patient has made progress in rehabilitation with a return to functional status with therapeutic services. The patient was able to ambulate 300 feet with a roller walker, and he was able to navigate 15 steps. The patient lives in a 1-bedroom apartment which requires 4 steps prior to entry. It is reasonable that if the patient can navigate down the steps and ambulate independently in his apartment, perform transfers independently, toilet, and feed himself he does not medically need long term care.