Diagnosis: colitis and suspected delirium tremens, erratic behavior, abdominal pain, and diarrhea.
Treatment: Alternate level of care.
The insurer denied coverage for alternate level of care.
The denial is upheld.

The patient is a male with chronic medical problems including hypertension, opioid dependence, and alcohol abuse. He was admitted to the nursing facility after being hospitalized and treated for colitis and suspected delirium tremens.

The patient was initially appropriate for the nursing facility care. (1, 2, 3) His clinical condition and functional deficits were amenable to medical intervention and comprehensive rehabilitation. However, according to the Progress note from the physical medicine and rehabilitation medicine specialist, the patient was "felt to have reached a highest practical functional level in a skilled rehabilitation program at this time and discharged from a skilled rehab program." The treatment notes from his other treating physicians and nursing staff do not support the medical necessity of an alternate level of care. The provider's appeal due to insurance and placement issues does not clinically support the continued stay at the nursing facility. The patient's clinical condition could have been safely monitored as an outpatient or home with home services.

The healthcare plan acted reasonably, with sound medical judgment, and in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation, and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board, and associations. All decisions are evidence-based).

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the alternate level of care was not medically necessary.

The insurer's denial of coverage for an alternate level of care is upheld. Medical Necessity is not substantiated.