Skilled Nursing Facility
Health Plan:
Metroplus Health Plan
Overturned overturned
Appeal Type:
Medical necessity
Age Range:
Decision Year:
Appeal Agent:
Kepro dba IMEDECS
Case Number:

Diagnosis: Vision. Treatment: Skilled Nursing Facility. The insurer denied Long-Term Custodial Care Services continued stay. The denial is overturned. The patient is a female with a medical history of diabetes mellitus type 2 with nephropathy, glaucoma, deep vein thrombosis (DVT), gastroesophageal reflux disease (GERD), bowel incontinence, urinary incontinence, atherosclerotic heart disease, congestive heart failure, chronic kidney disease, low back pain, GERD, hand osteoarthritis, history of retinal detachment, and hearing loss who has resided in a long-term care facility. The patient provided a letter stating she wanted to remain a long-term resident of the nursing home. The notes stated the patient had impaired gross motor and fine motor coordination. The patient appealed denial decision stating she had unstable diabetes and a cardiac condition, and she could not manage these conditions in a less supervised environment for example in an assisted living adult home or in a shelter. A nurse from the rehabilitation facility provided a letter that stated the patient required a skilled nurse for fingerstick and preparing and administration of insulin needed daily. The letter also stated the patient had glaucoma and a history of left cataract surgery and was unable to view medication for safe administration. In addition, the letter also stated the patient tired easily and required assistance with activities of daily living and was participating in physical and occupational therapy. The insurer sent final adverse determination denial notice denying request to extend long-term custodial care services stating they would stop. The denial stated there was no documentation of complete evaluation from a provider that showed the patient could not be safely discharged into a shelter or in the community. The medical director of the facility provided a progress note stating the patient's diagnoses, the patient needed close observation for all of her medical conditions and medical management as she was on multiple medications including insulin, gabapentin, Plavix, Lasix, Lipitor, multiple eyedrops for glaucoma, Eliquis, glipizide, hydralazine and due to her medical conditions the patient could not be transferred to a shelter as she needed close observation in a nursing home facility to prevent her from fall/hip fracture/intracranial bleed as she is on 2 different blood thinners for her heart conditions. The health plan's determination of medical necessity is overturned in whole. The requested health service/treatment of Long-Term Custodial Care Services continued stay is medically necessary for this patient. There is documentation by a registered nurse (RN) and a physician from the patient's long term care facility that she has medical diagnoses with active management which the patient is unable to manage on her own. The patient has poorly controlled diabetes as documented by blood sugar logs from long term care facility and requires sliding scale insulin typically 4 times per day. The patient's ophthalmologic conditions and neuropathy and arthritis make the patient unable to check her blood sugars on her own or administer her insulin. There is documentation of the need with assistance with medication administration, as well, due to her poor vision putting her at risk for medication errors which could result in harm. In addition, there is documentation of the patient's medical conditions and the medical necessity to continue at a long-term custodial level of care despite denial from insurer stating there was not a documentation of complete evaluation by provider that showed the patient could not safely be discharged into a shelter or the community. Therefore, the requested health service/treatment of Long-Term Custodial Care Services continued stay is medically necessary for this patient.