Inpt Discharge denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient skilled nursing facility (SNF) services and physical therapy, occupational therapy, and speech therapy services provided at Broadway by the Sea. Functional impairments due to acquired brain insults such as stroke can be severe to profound. One researcher notes that rehabilitation is an important aspect of the continuum of care in strokes, and that successful rehabilitation involves understanding the natural history of stroke recovery and a multidisciplinary approach to identify and treat common poststroke sequelae. A researcher notes that patients may improve spontaneously within the first three months and then more slowly in the coming year.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) level of care until the enrollee has open heart surgery. In this case, while the records do not document the patient’s disabilities in terms of patient’s ability to live independently or the degree of home support needed, the degree of right hemiparesis, possible dysphagia, visual acuity, exercise tolerance in general, ability to communicate and to manage medical conditions including diabetes preclude a safe discharge into the community. The records note that the patient lives alone and receives disability benefits, indicating that the patient has been disabled for a length of time.

Where the denial was upheld

Findings: The physician reviewer found that a patient has requested reimbursement and prospective authorization and coverage for continued inpatient level of care services, or in the alternative, acute rehabilitation services.Admission to an inpatient rehabilitation facility is intended to provide intensive rehabilitation therapy in a resource-intensive inpatient hospital environment for patients who have complex nursing and rehabilitation needs and require the medical management of a rehabilitation physician at least three days per week. Patients are expected to benefit from an inpatient stay and an interdisciplinary team approach to the delivery of rehabilitation care. This treatment plan includes ongoing treatment by physical and occupational therapies and speech-language pathology.

The enrollee is requesting authorization and coverage, and reimbursement, for skilled nursing facility (SNF) services. The enrollee was admitted to a skilled nursing facility (SNF) for the treatment of severe left hip osteoarthritis status post left total hip arthroplasty. The records indicate the enrollee received skilled physical therapy (PT)/occupational therapy (OT) services to enhance functional mobility skills and activities of daily living (ADLs). The enrollee was able to ambulate 35 feet with one rest period using a front wheel walker and requiring minimal assistance. Her physical status was touch down weight bearing. As part of the discharge plan, durable medical equipment, including a walker and home care referral were prescribed. However, the enrollee did not feel safe for home discharge because she was walking on tippy toes only, and could not walk.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Inpt Discharge, then check the rights and deadlines that apply to your plan.