Diagnosis: Diabetes, atrial fibrillation, end stage renal disease (hemodialysis) and multiple pressure ulcers

Treatment: Skilled nursing facility continued stay

The insurer denied coverage for Skilled nursing facility continued stay

The denial is overturned


This is an adult with multiple medical problems including diabetes, atrial fibrillation, end stage renal disease (hemodialysis) and multiple pressure ulcers. She presented to the skilled nursing facility (SNF) and was treated with antibiotics (7 days) for cellulitis. She also received physical and occupational therapy. Under review is the medical necessity for continued stay in a SNF.

The patient was an appropriate candidate for the SNF subacute rehabilitation level of care. She had functional impairments amenable to (subacute) rehabilitation therapy. The physical and occupational therapy notes document continued improvement over the next several weeks. The patient improved from dependent to supervision level for activities such as toilet transfer and wheelchair mobility. Chair to bed transfers improved to the supervision level. She was also able to ambulate short distances (20-30 feet). This is particularly impressive given her multiple comorbid conditions and concurrent treatment for COVID pneumonia. In addition, her active comorbid medical conditions and associated treatments also supported her continued stay in a skilled nursing facility.

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 coverage for continued care in a skilled nursing facility (SNF) is substantiated.