Diagnosis: Osteoarthritis, Altered mental status.

Treatment: Continued skilled nursing facility stay.

The insurer denied coverage for the continued skilled nursing facility stay.

The denial is upheld.

This is a male patient with multiple chronic medical problems including osteoarthritis of the left knee, congestive health failure, end stage renal disease on hemodialysis, obstructive sleep apnea, and depression. The patient was treated at a hospital for altered mental status and was subsequently admitted to a Skilled Nursing Facility (SNF) for physical, occupational and speech therapy due to his deficits in mobility, range of motion, activities of daily living (ADLs) and cognition. The insurer has denied coverage for continued SNF stay after one month of stay as not medically necessary.

The clinical records do not demonstrate a level of participation or functional improvement to support the medical necessity of continued therapy/rehabilitation services at the SNF for the time period under review. The clinical records repetitively document the patient's non-compliance with rehabilitation services. The patient remained at the maximal assistance level without significant functional progress due to non-compliance and failure to participate. In addition, there were no nursing or physician notes documenting any specific complex nursing needs or acute medical issues, respectively that required ongoing inpatient skilled nursing or medical services.

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, continued SNF stay after one month of stay was not medically necessary.

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

The carrier's denial of coverage for continued SNF stay after one month of stay should be upheld. The medical necessity is not substantiated.