Inpt Early Discharge denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested skilled nursing facility treatment services for treatment of the enrollee’s traumatic brain injury. Findings: The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for continued skilled nursing facility treatment services has been established. In this case, the patient has severe brain injury and is in a vegetative state. Skilled nursing level care is for patients who are undergoing rehabilitation and have nursing needs. In this case, the patient has nursing needs. The patient requires monitoring in a facility with continuous pulse oximetry and registered nurses present. For the reasons provided, continued skilled nursing facility treatment services are medically necessary for treatment of the patient’s medical condition.

A 49-year-old male enrollee has requested rehabilitation at a skilled nursing facility for the treatment of his medical condition. Findings: The physician reviewer found that the medical literature indicates that recovery after stroke occurs fastest in the first three months. Later recovery (up to one to two years after stroke) is also possible, especially between three to six months. Therefore, continued rehabilitation is generally appropriate for a patient who has had a recent stroke (within the last three months). While this patient’s condition was somewhat limited by his medical problems, he demonstrated some improvement during his stay in the skilled nursing facility and was continuing to progress. In light of his capacity for further improvement, his continued stay during the time period in question was medically appropriate and indicated.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A 63-year-old male enrollee has requested authorization and coverage for continued skilled nursing facility services from November of 2018 through December of 2018 including the assistance of multiple caregivers to provide the enrollee with physical therapy two times per day to combat paralysis; getting into and out of bed from a wheelchair and support sitting up; showering; changing his involuntary bowel movements three to four times daily; and daily dissemination of medication for blood pressure and diabetes.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and continuous coverage of a skilled nursing facility, level II care from 8/22/18 forward. Per a study, mild to moderate nonpurulent skin/soft tissue infections such as limb cellulitis are treated with intravenous and/or oral antibiotics. Another study note that lymphedema is a chronic condition that is managed with interventions such as manual decompression, limb compression pumps, compression wrapping/taping, compression sleeves and skin care The records in this case indicate that the patient was on oral antibiotics upon admission to the skilled nursing facility on 7/19/2018, with an order for a course of one week. Nursing evaluation did not note any significant wounds, skin lesions or other need for skilled nursing care with respect to his admission diagnosis of cellulitis.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Inpt Early Dischargewhen you appeal: reviewers routinely find that denials like yours didn’t hold up.