Diagnosis: Traumatic brain injury (TBI).
Treatment: Skilled nursing facility (SNF) admission.
The insurer denied coverage for a skilled nursing facility admission.

The denial is upheld.

According to the medical records, the patient is a male who fell off a ladder and had a subarachnoid hemorrhage; he had hydrocephalus and exterior shunt. He had a percutaneous endoscopic gastrostomy (PEG) tube, was aphasic, and had a stay at a rehabilitation and was transferred to a skilled nursing facility and has a decubitus ulcer. Later, he was admitted to the hospital for hypernatremia and fevers. He was treated with antifungals and antibiotic and got a new suprapubic catheter. He was suspected of having a urinary tract infection and had a wound vac placed. He was denied readmission to SNF.

Lueckel, S. N. et al. conclude "Our results suggest that among patients with traumatic brain injury admitted to skilled nursing facilities, the likelihood of adverse outcomes varies significantly by key demographic and clinical characteristics. These findings may facilitate setting expectations among patients and families as well as providers when these patients are admitted to skilled nursing facilities for rehabilitation after their acute episode." (2019).

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

He requires supportive care and 24-hour nursing. He is severely cognitively impaired. He was noted to open eyes to sound some spontaneous movement. No information regarding progress during prior SNF stay or goals achieved or the number of days he previously had. There was only one therapy session, and it was more of a brief assessment rather than an actual visit. Therefore, a skilled nursing facility admission at is not considered medically necessary for this patient.

The insurer's denial of coverage for skilled nursing facility admission is upheld. Medical necessity is not substantiated.