Rehab/Svcs SNF Inpt 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 and prospective authorization and coverage for skilled nursing facility (SNF) services, including speech therapy, physical therapy, and occupational therapy. As noted in the medical literature, admission to 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 treated in a SNF require skilled nursing services including wound management, tracheostomy care, bowel and bladder training and tube feeding, and administration of intravenous (IV) medications or medications that cannot be self-administered safely.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement and prospective authorization and coverage for acute rehabilitation services, or in the alternative, skilled nursing facility (SNF) level of care services. The records indicate that this patient has a history of diabetes mellitus type II, hypertension, and chronic kidney disease. The patient was admitted to the hospital for a stroke with left-sided hemiparesis, dysarthria, and dysphagia due to an occlusion of the right posterior cerebral artery. The patient underwent a thrombectomy and the hospital stay was notable for a urinary tract infection requiring antibiotics. The patient was admitted to acute inpatient rehabilitation. The patient’s acute inpatient rehabilitation stay was notable for acute diverticulitis, and he was started on prophylactic antibiotics.

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.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for residential treatment center substance abuse level of care.The submitted documentation does not support that residential treatment center substance abuse level of care was medically necessary. During the period in issue, the patient did not describe active suicidal ideation, and she showed cooperative behavior in treatment with no suicidal ideation or gestures. The progress notes indicate that the patient was open and honest in regards to her feelings about her mood, her feelings about her relationship with her family, and substance use. The patient did not display aggression towards peers or staff during the period in issue.

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 rehab/svcs snf inpt, then check the rights and deadlines that apply to your plan.