Diagnosis: Chronic obstructive pulmonary disease, bipolar disorder, schizophrenia, cerebrovascular accident

Treatment: Long-term care admission

The insurer denied coverage for long-term care admission

The denial is overturned.

This is an adult patient with chronic medical problems including chronic obstructive pulmonary disease (COPD), bipolar disorder and schizophrenia. The patient was admitted to the skilled nursing facility (SNF) for subacute rehabilitation after transfer from the hospital for left hemiparesis due to a stroke. Under review is the medical necessity for long-term care admission.

The patient was medically stable, and care is primarily custodial. However, long-term care placement was medically necessary, as services could not have been provided at a lower level of care (home with custodial home health aide services) in this particular situation. In addition, and according to the therapy notes, the patient made improvements with functional mobility during the time period under review. While modest, the improvements were sufficient to support the medical necessity of long-term care. This is particularly salient given the patient's eventual discharge to a shelter and need for highest functional level attainable in that specific environment. This physician would agree long-term care (custodial room and board) was clinically appropriate and medically necessary in this particular case. From a physical medicine and rehabilitation perspective, long-term care admission was medically necessary.

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, 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.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the long-term care admission is substantiated.