Inpt Trnsf To LLC denials in California external review

What the reviewers wrote

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 reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services. Admission to a SNF is appropriate for patients with conditions that require observation, evaluation of treatment plans, and updating of orders by a physician as well as constantly available skilled nursing services. Additional indication for skilled nursing services include wound management, tracheostomy care, bowel and bladder training and tube feeding, and administration of intravenous (IV) medications or medications that cannot be safely self-administered. Patients typically also benefit from skilled therapy services due to physical limitations, a significant decline in function or impaired cognition and communication with physical, occupational and speech therapies.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) skilled nursing level of care services and/or (2) physical therapy five times per week. Admission to a skilled nursing facility (SNF) is appropriate for patients with conditions requiring observation, treatment plan evaluation, and physician updating orders along with constantly available skilled nursing services. Skilled nursing services may include wound management, tracheostomy care, bowel and bladder training, tube feeding, and administering intravenous (IV) medications or medications that cannot be self-administered safely. Skilled nursing observation may include regularly monitoring vital signs, skin in the setting of wounds, and intake and output.

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for continued skilled nursing level of care services including physical therapy and occupational therapy services.Admission to a skilled nursing facility (SNF) is appropriate for patients with conditions that require observation, evaluation of treatment plans, and updating of orders by a physician as well as constantly available skilled nursing services. Patients require skilled nursing services, including wound management, tracheostomy care, bowel and bladder training, tube feeding, and administration of intravenous (IV) medications or medications that cannot be self-administered safely. Patients at the SNF level of care also require skilled nursing observation, including regular monitoring of vital signs, skin in the setting of wounds, and intake and output.

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 Trnsf To LLC, then check the rights and deadlines that apply to your plan.