Diagnosis: Central Nervous System/Neuromuscular/Chronic Pain Syndrome
Treatment: Skilled Nursing Facility
The health plan denied the continued skilled nursing facility stay as not medically necessary.
The health plan's determination is upheld.

The patient is a male with diabetes, hypertension, CVA (cerebrovascular accident) and a right knee ACL (anterior cruciate ligament) rupture.
At issue is the medical necessity of the requested health service/treatment of a Skilled Nursing Facility Admission.

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

The requested health service/treatment of Skilled Nursing Facility Admission is not medically necessary for this patient. The patient is a male with diabetes, hypertension, CVA (cerebrovascular accident) and right knee ACL (anterior cruciate ligament) rupture. The occupational therapy note stated that he required minimal assistance for toileting, contact guard assistance for dressing upper body, moderate assistance for dressing lower body, and minimal assistance for bathing. The physical therapy note stated that he was performing bed mobility with set up, transfers with supervision, ambulating 100 feet with supervision with rolling walker, and walking up stairs with contact guard. Later, his left lower extremity strength was 4/5. He had no focal neurologic deficits. On a later date, the occupational therapy note stated that he required minimal assistance for toileting, contact guard assistance for dressing upper body, minimum assistance for dressing lower body, and minimal assistance for bathing. The physical therapy note stated that he was performing bed mobility with set up, transfers with set up, and ambulating 200 feet with supervision with rolling walker. The patient could participate in a home program to include strengthening, range of motion exercises, and functional exercises. Skilled Nursing Facility Admission is not medically necessary, as there was no documentation of significant improvement in bathing, dressing, transfers, toileting, or ambulation during the later time frame. The peer-reviewed medical literature in the United States at this time would not include the continued Skilled Nursing Facility Admission. Further, the medical standard of care does not support the continued Skilled Nursing Facility Admission. Additionally, the continued Skilled Nursing Facility Admission does not meet InterQual Criteria.