Skilled nursing and inpatient rehab: 24% of denials overturned

Year by year

By treatment

Treatments with at least 20 decisions, most decisions first. Rates on fewer than 20 decisions aren’t shown.

Recent decisions

The most recent decisions in the data, half overturned and half upheld. Each shows the reviewer’s published findings.

1. Upheld 2025 · Medical necessity · age 65+ Admission · Bones, joints and muscles The physician reviewer found that a patient has requested reimbursement for long-term care services. Per the medical records, the patient’s diagnoses include lumbar spinal stenosis, cervical spinal stenosis with myelopathy with unsteady gait, gastroesophageal…

   The physician reviewer found that a patient has requested reimbursement for long-term care services. Per the medical records, the patient’s diagnoses include lumbar spinal stenosis, cervical spinal stenosis with myelopathy with unsteady gait, gastroesophageal reflux disease (GERD), hereditary and idiopathic neuropathy, and urinary incontinence. In this clinical setting, given that submitted records do not document that the patient required or requires the level of observation and treatment provided in terms of physician oversight and daily skilled nursing care and therapy services in the setting at issue that could not be provided in a setting of lower acuity, long-term care services were not medically necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness, or injury. Final Result: The reviewer determined that the services at issue were not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46378

2. Upheld 2025 · Medical necessity · age 65+ Admission · Brain and nerves The physician reviewer found that a patient has requested reimbursement for Level 2 skilled nursing facility (SNF) services, including physical therapy, speech therapy, occupational therapy, and physician care, and prospective authorization and coverage for…

   The physician reviewer found that a patient has requested reimbursement for Level 2 skilled nursing facility (SNF) services, including physical therapy, speech therapy, occupational therapy, and physician care, and prospective authorization and coverage for readmission to a Level 2 SNF that includes physical therapy, speech therapy, occupational therapy, and physician care. The records indicate that this patient presents with a history of acute toxic metabolic encephalopathy, hypothyroidism, and urinary retention. The patient’s medical history is also significant for type II diabetes mellitus, hyperlipemia, and morbid obesity. The patient was initially hospitalized for altered mental status and generalized weakness with pancreatitis and hypokalemia. The patient had been experiencing a decline in cognition prior to being hospitalized. The patient was found to have metabolic encephalopathy with brain magnetic resonance imaging (MRI) findings consistent with a metabolic encephalopathy pattern. On review of the records, the patient did not and does not require the level of observation and treatment provided in terms of physician oversight and skilled nursing care provided at an SNF. By the date of denial, the patient’s Foley catheter was removed, and the patient was able to urinate without issues. The patient was eating a regular diet and tolerating oral medications. The patient did not require daily skilled nursing services, including complex wound management, tracheostomy care, bowel and bladder training, and tube feeding, or administration of intravenous medications. The patient was independent with bed mobility and required supervision for transfers and contact guard assistance for ambulating with a walker. The patient continued to have confusion and poor memory, which the records suggest was likely the patient’s cognitive baseline. Although the patient may continue to benefit from occupational and physical therapy and assistance or supervision for safety, this did not and does not require the intensity of skilled therapy services provided in the SNF setting. Therefore, the Level 2 SNF services, including physical therapy, speech therapy, occupational therapy, and physician care, and readmission to a Level 2 SNF that includes physical therapy, speech therapy, occupational therapy, and physician care, were not and are not medically necessary for the treatment of the patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46312

3. Upheld 2025 · Medical necessity · age 65+ Admission · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for skilled nursing facility (SNF) services. In this clinical setting, the patient does not require the level of observation and…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for skilled nursing facility (SNF) services. In this clinical setting, the patient does not require the level of observation and treatment provided in terms of physician oversight and SNF care. The patient is tolerating a regular diet and oral medications, including pain medications. The patient is noted as being medically stable. The patient does not require daily skilled nursing services, including complex wound management, tracheostomy care, bowel and bladder training, and tube feeding, or the administration of intravenous (IV) medications. The patient’s physical therapy documentation indicates that the patient required supervision for bed mobility and minimal assistance for transfers. The patient was able to maneuver a manual wheelchair. In addition, a review of the medical documentation reflects that the patient’s providers cleared the patient for discharge home. The patient may benefit from occupational and physical therapy, assistance, or supervision. However, the documentation provided does not support that the patient requires the intensity of skilled therapy services provided in the SNF setting. Therefore, the requested SNF services are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services are not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46287

4. Overturned 2025 · Medical necessity · age 11–20 Admission · Injury The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services.The records indicate that this patient sustained a spinal…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services.The records indicate that this patient sustained a spinal cord injury (SCI). The patient is status post C3-T1 posterolateral fusion and C4-6 laminectomy. The patient was admitted to acute inpatient rehabilitation and then to a subacute rehabilitation facility. Currently, the patient requires maximum assistance for bed mobility and seated balance. The patient is dependent on others for transfers, dressing, and bathing. The patient requires minimal assistance with eating and maximum assistance for grooming. The patient requires a bowel program and intermittent catheterization. On review of the documentation, the patient continues to require the level of observation and treatment provided in terms of physician oversight and daily skilled nursing care provided in the SNF treatment setting. The patient sustained a cervical SCI with quadriplegia and neurogenic bowel and bladder. The patient was admitted to acute inpatient rehabilitation and then to a subacute rehabilitation facility for continued rehabilitation. The patient continues to require physician oversight and management of his pain, spasticity, and neurogenic bowel and bladder. The patient requires daily skilled nursing care, including bowel and bladder training. The patient continues to require maximum assistance for bed mobility and seated balance. The patient has made some progress with therapy. Currently, ongoing therapy services in the SNF treatment setting are indicated to maximize the patient’s potential recovery and independence in terms of mobility and management of neurogenic bladder before being discharged. Overall, the patient would continue to benefit from the intensity of skilled therapy services in the SNF setting, including physical and occupational therapies. Therefore, the SNF services were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46243

5. Upheld 2025 · Medical necessity · age 65+ Admission · Hormones and metabolism The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for skilled nursing facility services. In this case, the patient was admitted to a skilled nursing facility following…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for skilled nursing facility services. In this case, the patient was admitted to a skilled nursing facility following hospitalization for an L1 compression fracture after a fall that did not require surgery. Upon discharge from the skilled nursing facility, the patient required supervision for bed mobility, transfers, and ambulating with a walker, and required assistance for activities of daily living including dressing, bathing, and toileting. The patient’s skin was intact with no wounds. The patient was subsequently discharged to independent living, then assisted living, and later transferred to a board and care facility. Currently, the patient resides in a board and care facility and is confined to bed with assistance required for daily activities.Based on the records, there is no indication that the patient requires daily skilled nursing services such as complex wound management, tracheostomy care, bowel and bladder training, tube feeding, or administration of intravenous medications. Although the patient has experienced a decline in mobility and may benefit from therapy services, this does not require the intensity of skilled nursing facility level care, and therapy can be provided at a lower level of care. All told, the requested skilled nursing facility services are not necessary to protect life, prevent significant illness or disability, or alleviate severe pain through the diagnosis or treatment of disease, illness, or injury. In addition, the requested services are not necessary for the patient to achieve or maintain functional capacity. Therefore, the requested skilled nursing facility services are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and is knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46149

6. Upheld 2025 · Medical necessity · age 65+ Discharge · Hormones and metabolism The physician reviewer found that a patient has requested reimbursement for any or all of the skilled nursing facility services, including: occupational therapy and physical therapy. Based on the records, the patient did not require the level of observation…

   The physician reviewer found that a patient has requested reimbursement for any or all of the skilled nursing facility services, including: occupational therapy and physical therapy. Based on the records, the patient did not require the level of observation and treatment provided in terms of physician oversight and skilled nursing care. The patient sustained a right patellar fracture after a syncopal episode. The patient was evaluated by an orthopedic surgeon who deemed that no surgical intervention was indicated. The patient was discharged to a subacute rehabilitation facility, but was ultimately admitted to the hospital due to pneumonia. The patient was treated with antibiotics and evaluated by a nephrologist for acute kidney injury. The patient was admitted to a skilled nursing facility. Approximately three months later, the patient was medically stable and tolerating a regular diet and thin liquids and oral medications. The patient did not require daily skilled nursing services, including complex wound management, tracheostomy care, bowel and bladder training and tube feeding, or administration of intravenous medications. The patient was requiring moderate assistance for toileting and bathing, and contact guard assistance for hygiene and grooming care. The patient required minimum assistance for lower body dressing and set up assistance for upper body dressing. The patient required minimum assistance for bed mobility, moderate assistance for transfers, and minimum assistance for ambulating with a walker. The patient’s progress with therapies plateaued. The patient may have continued to benefit from occupational and physical therapy and assistance or supervision. However, this did not require the intensity of skilled therapy services provided in the skilled nursing facility setting. Given these findings, all of the skilled nursing facility services, including: occupational therapy and physical therapy, were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46052

7. Upheld 2025 · Medical necessity · age 41–50 Admission · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for skilled nursing facility services, including physical therapy. Skilled nursing facility care is indicated for patients who…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested authorization and coverage for skilled nursing facility services, including physical therapy. Skilled nursing facility care is indicated for patients who require ongoing skilled nursing services, close medical monitoring, or intensive rehabilitation that cannot be safely or effectively provided at a lower level of care. In this case, the patient is medically stable and does not require the level of physician oversight, skilled nursing services, or intensity of rehabilitation provided in a skilled nursing facility setting. The available documentation does not demonstrate a need for continued care at this level. Therefore, the requested skilled nursing facility services, including physical therapy, are not medically necessary for the treatment of this patient. Final Result:The reviewer determined that the requested services are not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications:The reviewer is board-certified in physical medicine and rehabilitation and is actively practicing. The reviewer is knowledgeable about the proposed treatment through recent or current clinical experience treating those with the same or a similar medical condition.

   Case MN25-45843

8. Overturned 2025 · Medical necessity · age 51–64 Admission · Heart and circulation The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for admission into an acute inpatient rehabilitation facility (IRF). Acute IRF is indicated for this patient. The subacute stage…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for admission into an acute inpatient rehabilitation facility (IRF). Acute IRF is indicated for this patient. The subacute stage after a stroke occurs anywhere from one week to three-to-six months post-stroke. During this period of time, the patient should have more intensive rehabilitation efforts aimed at promoting neurological recovery and improving functional abilities. A comprehensive stroke rehabilitation program is critical to optimize post-stroke outcomes. Additionally, the patient still presents with significant functional limitations, including requiring maximum assistance for transfers, and needs access to equipment to modify activities. The patient also recently received ankle-foot orthoses (AFOs). Given these findings, the requested admission into an acute IRF is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollee's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-44783

9. Overturned 2025 · Medical necessity · age 51–64 Admission · Hormones and metabolism Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement 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…

   Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement 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. Skilled nursing services include 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 admitted to a SNF also require skilled nursing observation, including regular monitoring of vital signs, skin in the setting of wounds, and intake and output. These patients typically also benefit from skilled therapy services due to physical limitations or a decline in function. Skilled therapy services include physical and occupational therapies. In this case, the patient required the level of observation and treatment provided at the SNF in terms of physician oversight and skilled nursing care. The records indicate the patient was transferred back to the SNF following a readmission to the hospital for hypokalemia. The records show that the patient continued to benefit from daily skilled nursing care, which included monitoring of the patient’s medications and medical conditions, as well as bladder training for removal of a Foley catheter. The patient was also making objective progress with both physical and occupational therapies and continued to make progress until prior to discharge. Overall, the patient was benefiting from the intensity of skilled therapy services provided in the SNF setting for the period under review. For these reasons, the SNF services provided were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollee's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-44568

10. Overturned 2025 · Medical necessity · age 41–50 Admission · Injury The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for comprehensive neurorehabilitation in an acute inpatient rehabilitation facility; or long-term acute care hospital (LTACH) level…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for comprehensive neurorehabilitation in an acute inpatient rehabilitation facility; or long-term acute care hospital (LTACH) level of care services with embedded or coordinated neurological rehabilitation services; or standard LTACH level of care services; or daily physical therapy (PT) services; or daily speech therapy (ST); or daily occupation therapy (OT) services. According to researchers, when determining the level of care for patients with disorders of consciousness (DOC), the recommendation for a less intense setting should occur “when the need for specialized evaluation and treatment slows.” The authors noted that as medical acuity and rehabilitation needs diminish, lower-intensity skilled nursing, outpatient, or home-based services can be provided. In this case, the records show that the patient is demonstrating medical stability from a respiratory perspective and no significant response to recent therapy interventions. Studies show that patients with an extended duration of vegetative and coma states have poorer functional outcomes, and that all patients with bilateral lesions of the basal ganglia, as is the case with this patient, also experience poorer outcomes. Conversely, one study showed a predicted consciousness recovery at 12 months, with clinical improvement expected up to 24 months for younger-aged female patients in a coma state. However, there is a lack of medical literature describing a specific intensity or frequency of rehabilitation that will expedite this recovery. One study found that patients in a vegetative or minimally conscious state who were admitted to a LTACH were less likely to transfer to the emergency room (ER). These patients were also less likely to be admitted back to an acute care hospital compared to patients with mild to moderate or no cognitive impairment. As such, LTACH is supported as the best level of care for patients in a persistent vegetative state with ongoing respiratory needs.Overall, based on the medical literature and the submitted records, comprehensive neurorehabilitation in an acute inpatient rehabilitation facility is not indicated for this patient. Moreover, there is no support in the medical literature for the intensity or need for embedded or coordinated neurological rehabilitation services in the LTACH setting to promote the patient’s neurologic recovery. The medical literature supports standard LTACH level of care as the appropriate setting of care for this younger female patient, as she will be less likely to be transferred to the ER or an acute care hospital. Given these findings, the requested standard LTACH level of care services are medically necessary for the treatment of this patient. Final Result: The reviewer determined that standard LTACH level of care services are medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be partially overturned. Credentials/Qualifications: The reviewer is board-certified in physical medicine and rehabilitation with subspecialty certification in brain injury medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollee's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN25-44400

11. Overturned 2025 · Medical necessity · age 51–64 Inpt trnsf to LLC · Infection 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…

    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. Further, the patient required treatment of multiple infections with IV antibiotics based on positive urine cultures, positive cultures of wounds, and positive cultures of sputum. The record establishes that the patient had hemodynamic instability with tachycardia and hypotension in the setting of severe systolic heart failure for which cardiology services were required. The patient was experiencing continued compromise and decline in her respiratory status, with increasing respiratory support. Wound care was escalated, requiring the application of wound vacuum-assisted closure (VAC). The patient again experienced sepsis, requiring IV antibiotics. A review of the patient’s laboratory data and vital signs during the time period for review was severely abnormal. In addition, the patient’s respiratory status continued to decline, requiring mechanical ventilation and therapeutic bronchoscopy for clearance of large amounts of mucous plugs and secretions. The patient experienced another episode of respiratory failure from pneumonia with mucous plugs, undergoing another round of therapeutic bronchoscopy. Overall, there is sufficient support in the clinical practice guidelines and clinical picture of this patient that the request for coverage of LTACH level of services was and is reasonable and appropriate in this clinical setting. Thus, the LTACH level of care services were and are medically necessary for the treatment of this patient’s intensive care health conditions. Final Result: The reviewer determined that the services were and are medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollee's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN25-44111

12. Overturned 2025 · Medical necessity · age 51–64 Admission · Heart and circulation 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…

    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. Prior to the stroke, the patient was independent with mobility and performing daily activities. Upon admission to acute inpatient rehabilitation, the patient was noted to have left-sided neglect with mild cognitive and communication deficits, including problem-solving. As of the date of denial, the complexity of the patient’s nursing medical and rehabilitation needs did not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was initially admitted to the hospital for a stroke with left-sided hemiparesis, dysarthria, and dysphagia due to an occlusion of the right posterior cerebral artery. As of the date of denial, the patient was medically stable, tolerating oral medications, and did not require feeding through a tube, tracheostomy management, or complex wound care. The patient was unable to be discharged from the acute inpatient rehabilitation setting because there was a lack of appropriate caregiver assistance at home. The patient did not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program at least three hours a day and five days a week, or 15 hours over seven consecutive days. As of the date of denial, the patient was receiving speech therapy for compensatory strategies regarding neglect. The patient required maximum assistance for bed mobility and transfers, was dependent for most daily activities, and family caregivers had been educated in terms of patient safety. The patient’s progress with therapy was not at the pace that would require the intensity of therapies provided in acute inpatient rehabilitation. As of the date of denial, the patient was a candidate for transfer to an SNF. The patient continues to require daily skilled nursing care for the management of bowel and bladder as well as nutritional and medication monitoring. Given the gradual progress, the patient is likely to continue to benefit from subacute rehabilitation services, including physical, occupational, and speech therapies in the SNF setting. Therefore, the acute rehabilitation services were not and are not medically necessary for this patient, while the requested SNF level of care services are medically necessary for the treatment of this patient. Final Result: The reviewer determined that a portion of the requested services are medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be partially overturned. Credentials/Qualifications: The reviewer is board-certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN25-43677