Diagnosis: Foot Disorder.
Treatment: Skilled Nursing Facility.
The insurer denied Continued Skilled Nursing Facility Care.
The denial was upheld.

The patient is a female with a history of diabetes, obesity, lymphedema, and a left foot wound treated previously with artificial skin grafts times (x) 2 and planning to have a third artificial skin graft. The patient was previously treated with daily dressing changes and wound checks.
The patient was admitted to the Skilled Nursing Facility for wound care, which consisted of daily dressing changes. Her wound vacuum-assisted closure (VAC) was discontinued. She was scheduled for a third Theraskin application, which was managed by the Wound Center. Bilateral lower extremity range of motion was normal. The strength was normal in the upper extremities and strength was 3/5-4 plus (+)/5 in the lower extremities.
She was hemodynamically stable and afebrile. Her blood sugar was well controlled, and her oxygen saturation was normal on room air. She had refused all vaccinations and was a do not resuscitate (DNR). Her pain level was 0. She ambulated with a walker. She was independent with eating, required minimal assistance with toileting, independent with sit to stand transfers, was able to propel her wheelchair 10 feet with contact guard assistance, ambulated greater than (>) 150 feet with bilateral crutches and standby assistance, and required minimum to moderate assistance with dressing.
At issue is the medical necessity of Continued Skilled Nursing Facility Care.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Continued Skilled Nursing Facility Care was not medically necessary for this patient.
The patient did not have a continued need for physical therapy services that could not be provided outside of a skilled nursing facility, did not have a need for continued occupational therapy services that could not be provided outside of a skilled nursing facility and did not have skilled needs provided by a medical professional such as a physician or a nurse such as complicated wound care. She required daily dressing changes and this type of care is not considered medically complicated or complex. She was independent with eating, required minimal assistance with toileting, independent with sit to stand transfers, was able to propel her wheelchair 10 feet with contact guard assistance, ambulated > 150 feet with bilateral crutches and standby assistance, and required minimum to moderate assistance with dressing. Per the documentation, the care the patient was receiving does not require an inpatient skilled nursing facility.
Therefore, continued inpatient skilled nursing facility care is not medically necessary.