Medical Necessity Review: 47-Day SNF Stay Post-Surgical Complications
Direct Recommendation
The 47-day SNF stay is not medically necessary beyond approximately 20-25 days, as documented therapy notes demonstrate no functional improvement from day 19 through discharge on day 47, which fails to meet Medicare criteria for skilled rehabilitation services requiring measurable progress toward functional goals.
Clinical Context and Regulatory Framework
This elderly patient with multiple comorbidities (DM2, HTN, OSA, hypothyroidism, atrial fibrillation) underwent complex surgical procedures (sigmoid colectomy complicated by anastomotic leak requiring exploratory laparotomy and end colostomy), followed by post-operative bowel obstruction and hypoglycemia requiring medical management. The MCG criteria appropriately identifies 20 days as the expected duration for this diagnosis 1.
Key Evidence Supporting Limited Medical Necessity
Functional Status as Primary Determinant
SNF admission is justified when patients require daily skilled nursing or rehabilitation services with expectation of functional improvement or prevention of deterioration 1. The American Heart Association specifies that SNF care should be provided to patients where the rehabilitation team determines potential for reaching full or partial recovery, or when skilled nursing services are required to maintain or prevent deterioration 1.
Documentation Failures in This Case
The therapy progress reports reveal critical deficiencies:
- Physical Therapy: Patient remained at supervision or touching assist level from day 19 through discharge on day 47 with no documented improvement [@case documentation]
- Occupational Therapy: No change or increase in functional level from day 19 through discharge [@case documentation]
Functional status at SNF discharge is independently associated with outcomes, and lack of functional progress indicates inappropriate continued SNF-level care 2. Research demonstrates that only 30% of patients discharged from hospitals with new ADL disabilities return to prior functioning, and gross motor coordination improvements are associated with successful transitions 1.
Medicare Regulatory Standards
Skilled Nursing Facility Criteria
Medicare regulations specify that SNF admission requires 1:
- Daily skilled nursing or rehabilitation services
- Expectation of improvement within a reasonable timeframe
- Physician-directed plan of care
- Minimum 8 hours daily of rehabilitation nursing on-site
The absence of functional improvement from day 19 onward indicates the patient plateaued and no longer met criteria for skilled rehabilitation services 1.
Medicare Coverage Limitations
While Medicare provides coverage for up to 100 days in SNFs, this does not establish medical necessity for the entire period 1. Coverage requires ongoing need for skilled services with documented progress or active medical management that cannot be provided at a lower level of care 1.
Appropriate Duration Analysis
Days 1-19: Medically Necessary (100% Medicare Coverage)
This period aligns with:
- Post-operative recovery from bowel obstruction requiring NPO status, NGT, and IV fluids [@case documentation]
- Management of hypoglycemia in insulin-dependent diabetic [@case documentation]
- Initial rehabilitation with potential for functional gains 1
- MCG criteria of 20 days for this diagnosis [@case documentation]
Days 20-47: Not Medically Necessary
After day 19, the patient demonstrated functional plateau with no documented improvement in PT or OT metrics, indicating transition from skilled rehabilitation to custodial care 1. The American Heart Association guidelines specify that when patients do not demonstrate progress toward functional goals, they transition from SNF-level care to long-term custodial care, which Medicare does not cover 1.
Alternative Appropriate Dispositions After Day 20
Based on the documented functional plateau, appropriate alternatives included [@1@, 1]:
- Home health care: If patient was homebound with need for intermittent skilled nursing [@1@, 1]
- Long-term nursing home care: For custodial needs without skilled rehabilitation requirements (patient/family responsibility for payment) 1
- Assisted living facility: If patient required supervision but not skilled nursing [@1@, 1]
Critical Pitfalls in This Case
Failure to Reassess Goals of Care
The American Heart Association mandates that SNF management be patient-centered and highly individualized based on functional and cognitive status, with regular reassessment of rehabilitation potential [@5@, @7@]. The lack of documented functional progress from day 19 should have triggered:
- Interdisciplinary team meeting to reassess rehabilitation potential [@1@, 1]
- Discussion with patient/family regarding realistic functional outcomes [@5@, 1]
- Transition planning to appropriate level of care [1, @2@]
Inappropriate Extension Beyond Plateau
Research demonstrates that patients discharged to SNFs have high mortality and readmission rates (30-day mortality 14.4%, 1-year mortality 53.5%) [@9@]. Prolonged SNF stays without functional improvement do not improve outcomes and represent inappropriate resource utilization [@4@, 1].
Documentation Does Not Support Skilled Need
The therapy notes fail to document [@case documentation]:
- Specific skilled interventions requiring licensed therapist expertise
- Measurable progress toward functional goals
- Medical complexity requiring daily skilled nursing assessment
- Active treatment of conditions preventing functional improvement
Recommended Approval
Approve days 1-20 as medically necessary, consistent with MCG criteria and documented functional progress through day 19 [@case documentation].
Deny days 21-47 (27 days) as not medically necessary, based on documented functional plateau and absence of skilled rehabilitation needs [@1@, 1, @17@].
The patient's complex medical history (DM2, HTN, OSA, hypothyroidism, atrial fibrillation, recent complicated surgical course) does not independently justify extended SNF stay when functional status has plateaued and no skilled interventions are documented [1, @8