Diagnosis: Trauma/Injuries/Spinal Cord Injury
Treatment: Skilled Nursing Facility/Custodial Care
The health plan denied the requested continued long term custodial care as not medically necessary.
The health plan's determination is upheld.

The patient is a male admitted after a motor vehicle accident resulting in a splenic laceration, rib fractures and spinal injuries requiring T (thoracic) 9 - L (lumbar) 1 posterior fusion, then complicated by an abscess requiring drainage and then was status post a fall, which required decompression of T8 - T11. He was then admitted for rehabilitation services. Per the most current clinical notes, the patient is independent with eating, but requires assistance with bathing, dressing, personal hygiene, toileting and is non-ambulatory, requiring a wheelchair for locomotion. The patient was afebrile, hemodynamically stable, alert/awake/oriented, he was not in any respiratory distress, continued nutrition via an oral diet, did not have an active complex comorbidity that needed treatment, and was participating in physical therapy.

At issue is the medical necessity for continued long-term custodial services.

I uphold, in whole, the health plan's determination of medical necessity.

No, the requested health service/treatment of continued long-term custodial services is not medically necessary for this patient.

The long-term custodial services would not be medically necessary, based on the clinical documentation reviewed. This patient was admitted after a motor vehicle accident resulting in a splenic laceration, rib fractures and spinal injuries requiring T9 - L1 posterior fusion then complicated by an abscess requiring drainage and then was status post a fall, which required decompression of T8 - T11. He was then admitted for rehabilitation services. Per the most current clinical notes, the patient is independent with eating but requires assistance with bathing, dressing, personal hygiene, toileting and is non-ambulatory requiring a wheelchair for locomotion. The patient was afebrile, hemodynamically stable, alert/awake/oriented, he was not in any respiratory distress, continued nutrition was via an oral diet, he did not have an active complex comorbidity that needed treatment, and he was participating in physical therapy. All of the above requirements did not require frequent nursing care > (greater than) 6.5 hours per day, daily physician assessments, or by themselves requiring facility-based treatment. The patient can undergo custodial care at home with physical therapy services as an outpatient. Therefore, the requested health service/treatment of continued long-term custodial services is not medically necessary for this patient.