Skilled Nursing Facility Rehabilitation denials in California external review

What the reviewers wrote

Where the denial was overturned

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.

A 46-year-old male enrollee has requested continued rehabilitation therapies and skilled nursing services for the treatment of the enrollee, who is status post pelvic fracture. Findings: The physician reviewer found that the patient was not safe for discharge during the dates of service at issue, and he was progressing with physical therapy and occupational therapy. His needs were not custodial. The prevailing practice standard is to complete rehabilitation for patients transferred to a skilled nursing facility for rehabilitation. In this case, the patient’s skilled nursing facility-based rehabilitation was not complete as of the last authorized date of service and it would not have been reasonable to provide the patient with a lower level of care. The Health Plan’s assessment of the patient’s needs was not consistent with his clinical course in rehabilitation.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled and rehabilitative services performed at a skilled nursing facility (SNF). There is a paucity of evidence to support intensive rehabilitation interventions during the period of immobilization and weightbearing restrictions following ankle fractures, per researchers. The focus of rehabilitation during this time is to acquire compensatory skills to manage functionally in as independent a manner as possible given the acute impairment and comorbid conditions.

Nature of Statutory Criteria/Case Summary: An enrollee has requested skilled nursing/rehabilitative services for treatment of the enrollee, who is status post cerebral vascular accident. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. Functional impairments due to acquired brain insults such as stroke can be profound. Nevertheless, some recovery is expected with time, and many of these impairments are amenable or addressable by compensatory measures by directed rehabilitation efforts. The role of inpatient rehabilitative care for persons with significant functional deficits following stroke is relatively well-established in the medical literature. In this case, the patient has had major functional deficits following his stroke.

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 Skilled Nursing Facility Rehabilitation, then check the rights and deadlines that apply to your plan.