Diagnosis: Central Nervous System/Neuromuscular Disorder - right temporal lobe hemorrhage.
Treatment: Inpatient Hospital.
The insurer denied continued skilled nursing stay.
The denial is upheld.

The patient is a male with a seizure disorder, treated to baseline with Keppra, poorly controlled diabetes mellitus with glycated hemoglobin (A1c) of 13, and hyperlipidemia, who suffered an intraparenchymal brain hemorrhage and status epilepticus, for which he was admitted to the hospital. The patient was intubated, and required mechanical ventilation, nicardipine drip, and Keppra reload. The computed tomography (CT) scan of the head demonstrated a right temporal lobe hemorrhage. His blood pressure was stabilized, and he was eventually extubated and stabilized. He was assessed at the medical facility by Physical and Occupational Therapy. He was deemed appropriate for subacute rehab, where he was transferred.

The question is whether the patient required additional skilled nursing facility stay.

The health plan's determination is upheld.

The patient actively participated in the rehabilitation process, and he showed a steady improvement during this time frame. The patient suffered a hemorrhagic stroke without focal deficits but exhibited gross weakness in all 4 extremities and some lightheadedness. By the end of the 21 days, the patient was ambulating 75 feet with supervision, performing transfers with supervision, was no longer lightheaded, had stable blood pressure, improved control of blood glucose values, and overall stability of the chronic medical problems. The goals of the skilled nursing facility stay were accomplished.

The provided documentation notes that the patient had appropriate progression in his physical activity, and improvement in activities of daily living (ADL) ability, by the time of discharge to progress to the next level of care.

The patient can ambulate 75 feet, per the last documented note, and only requires supervised transfers. Per activities of daily living scoring calculator, the patient falls between low-level ADL acuity and independent level ADL acuity. The patient is transitioning from subacute rehab into his sister's apartment, which has an elevator. A distance of 75 feet is adequate for the patient to safely traverse the distance from the living room to the kitchen and the bedroom. The patient is awake, alert, and oriented x 3, with a benign exam. The pain in the left shoulder appears chronic and can be assessed further in a lower level of care setting.

Based on the documentation, there are no clinical indications for ongoing skilled nursing facility stay.