Diagnosis: Acute cervical fractures

Treatment: Continued care in a Skilled Nursing Facility (SNF)

The insurer denied coverage for continued care in a Skilled Nursing Facility (SNF)
The denial is upheld.

This is a male with hypertension and alcohol dependence. He presented to the hospital emergency department "intoxicated after an altercation that day." Cervical spine X-rays demonstrated multiple chronic and acute cervical fractures. He was transferred to a SNF for subacute rehabilitation. He was approved for skilled services including physical therapy, occupational therapy and speech therapy. Under review is the medical necessity for continued care at a skilled nursing facility (SNF).

The patient was initially appropriate for the SNF subacute rehabilitation level of care (1, 2, 3). He had functional deficits that were amenable to comprehensive rehabilitation. He participated in physical and occupational therapy with demonstrated gradual improvement. According to the occupational therapy progress notes, the patient was at the "supervision" level for activities of daily living including dressing, hygiene and grooming. According to the physical therapy notes the patient was independent with bed mobility and transfer activities. He was able to ambulate "unlimited distances." According to the case notes, the patient was scheduled for discharge from the SNF. However, placement was difficult due to being homeless. A friend was willing to take him, and he was subsequently discharged. Given his functional level, skilled therapy services were no longer medically necessary. In addition, there were no acute medical or complicated nursing issues that required continued stay at the SNF for the time period under review.

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, continued care in an SNF was not medically necessary.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the continued stay in a skilled nursing facility is upheld. Medical Necessity is not substantiated.