Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 
The patient is a 52-year-old male who sustained a massive subarachnoid hemorrhage related to a ruptured right middle cerebral artery aneurysm on 3/08/21.  The patient has requested authorization and coverage for specialized, post-acute brain injury inpatient neurorehabilitation program services. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that functional impairments due to acquired brain insults such as subarachnoid hemorrhage related to aneurysmal rupture can be profound, especially with severe bleeds.  Nevertheless, some recovery is expected with time, i.e., natural recovery processes, and many impairments are amenable or addressable by compensatory measures and by directed rehabilitation efforts, particularly early rehabilitation interventions. The role of ongoing rehabilitative care for patients with significant functional deficits following acquired brain injuries is also relatively well-established in the medical literature. In this case, the patient has had major functional deficits following a ruptured right middle cerebral artery aneurysm in early March 2021.  He has been undergoing an intensive rehabilitation program.  There has been good physical recovery, but his primary limiting factors in further progression have been in the cognitive domain. His cognitive status has remained moderately to severely impaired. The patient will likely continue to recover some aspects of his cognitive function, which is the general expectation following brain insults such as the type that the patient has sustained, as recovery can occur for generally up to two years (or slightly longer) after these types of insults.  The course of recovery in this clinical setting, however, is such that much of this recovery happens in the earlier stages post-insult, and that subsequent recovery is more gradual.  The recovery in the more subacute and chronic stages, moreover, has not been proven to be amenable to intensive rehabilitation interventions, such that more intensive therapies in the later stages post-injury foster greater levels of recovery. This is particularly true with respect to impairments in the cognitive domain. It is unclear, in particular, whether these rehabilitative interventions aimed at fostering cognitive improvement can translate to functional gains useful to everyday functioning. This remains an area of active investigation. The brain primarily needs time and rest to heal and recover. The proposed transfer to another facility that provides intensive rehabilitation at the level of an acute inpatient rehabilitation center is not medically necessary because there is no expectation that continued high intensity rehabilitation services will positively influence his outcomes, given the lack of literature that establishes the efficacy of this intervention on a long-term basis. Therefore, specialized, post-acute brain injury inpatient neurorehabilitation program services are not medically necessary for the treatment of this patient.