Diagnosis: Cerebral infarction
Treatment: Nursing Home Service
The insurer denied the Nursing Home Service
The denial is upheld

The patient is a male with hyperlipidemia, deep venous thrombosis (DVT), seizure, insomnia, hypertension, bipolar, and cerebral infarction. The request is for Nursing Home Services. The patient walks with intermittent supervision, needs intermittent supervision with eating, and requires intermittent supervision with activities of daily living.

No, the proposed treatment was not medically necessary.
As per the records, the patient is a male with hyperlipidemia, deep venous thrombosis, seizure, insomnia, hypertension, bipolar, and cerebral infarction. The patient walks with intermittent supervision, needs intermittent supervision with eating, and requires intermittent supervision with activities of daily living. There are no needs for continued skilled nursing facility. The services can be provided in the community setting if needed.

The patient does not require supervision with mobility, or transfer, or toileting; the patient does not require any supervision with eating or feeding himself; the patient does not require any specialized services or physical recreational therapy. The services were requested because the patient was deemed without capacity by psych to make medical/financial decisions and is not able to take care of his own activities of daily living at times and family cannot provide care for this patient.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Based on the records, the patient did not need any continued skilled nursing facility care and can be safely and effectively treated in the community setting.