Pressure Ulcer: when insurers say no, reviewers often say yes

Where the denial was overturned

Findings: The physician reviewer found that a patient has requested authorization and coverage for long-term acute care hospital (LTACH) level of care services. In this case, the record establishes that the patient has end-stage multiple sclerosis with associated severe mobility and activities of daily living (ADL) impairments and associated neurogenic bladder. The patient was admitted initially to the acute care hospital with acute onset of sepsis related to urinary tract infection and infection of pressure sores involving the sacrum and bilateral ischium. The patient was also noted as experiencing respiratory failure for which a tracheostomy was placed. The patient was later transferred from the ICU to the LTACH for multiple medical problems. The patient required treatment of severe pain and agitation with Precedex.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for skilled nursing facility (SNF) level of care. Findings: As noted in the medical literature, SNF admission may be indicated for patients with more than one wound, including a stage 3 pressure ulcer, rehabilitation, gait training, and observation. One study noted that, “Pressure ulcers (PUs) are injuries to the skin and underlying tissues that occur most commonly over bony prominences, such as the hips and heels as a result of pressure and shear forces.” Another study analyzed 477 patient records to determine the percentage of patients with pressure ulcers/injuries (PU/Is) who required admission to a SNF for wound care. The authors found that the majority of patients with a PU/I required admission from home to a SNF for appropriate care.

Where the denial was upheld

An enrollee has requested authorization and coverage for in-patient acute level of care services.Irmak and colleagues state that, although reconstruction is still a controversial issue in elderly patients with advanced pressure ulcers, it has been established that infection, protein loss, morbidity, and mortality will increase in patients without proper debridement and reconstruction. Appropriate patient selection, debridement, and reconstruction with appropriate postoperative rehabilitation can be very beneficial in elderly patients. In patients whose general health condition is a contraindication for surgery, at a minimum, progression of pressure ulcers can be prevented with good wound care and conservative treatment.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services including physical therapy and occupational therapy services provided for treatment of the enrollee’s transient ischemic attack (TIA), epilepsy, and pressure ulcers. Findings: The physician reviewer found that based on the medical records provided for review, the SNF services including physical therapy and occupational therapy services provided were not and are not medically necessary for treatment of this patient’s medical condition. Patients require SNF services or skilled rehabilitation services when they are needed on a daily basis and the daily skilled services can be provided only on an inpatient basis in a SNF. The documentation does not reveal that this patient requires SNF services.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for pressure ulcer was denied, the published record says the denial is worth fighting.