Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Renal abscess status post interventional radiology drainage.
Treatment: Level 3 Subacute Rehabilitation Stay.
The insurer denied coverage for Level 3 Subacute Rehabilitation Stay.
The denial is upheld.

This patient was diagnosed with renal abscess status post interventional radiology drainage and was sent to rehabilitation on antibiotics for methicillin-resistant Staphylococcus aureus (MRSA) abscess. Records stated that the patient's plan approved 29 days of Level One subacute rehabilitation. The patient's provider requested approval for level 3 subacute rehabilitation increase throughout the same timeframe. Records noted that, the plan approved zero days of level 3 subacute rehabilitation and continue to approve the level 1 subacute rehabilitation throughout the timeframe in question. The indication was that level 3 services were not medically necessary. To approve the service, InterQual criteria Adult Subacute Rehabilitation must be met to include that there is documentation of an illness, injury, or flareup of an existing condition within the last 30 days or recent discharge from the hospital and there is a need for medical skilled nursing services at least daily and some type of new functional limitation requiring at least minimum or limited assistance from another person and a need for therapy services with at least 1 dose of plan (physical therapy, Occupational Therapy) with the potential to improve with the therapy and the inability to receive therapy services at home because the home is not suitable or the services are not available in the home.  

It was determined that these criteria were not met as medical records showed the patient was independent with activities of daily living with the ability to walk 200 feet without using any assistive device. The patient was getting medication intravenously twice a day to treat an infection. To meet the standards for an approval at level 3, there would need to be documentation of a need for at least 4 hours of skilled nursing services per day in addition to skilled rehab services being provided at least 5 times a week. The clinical notes do not support the need for additional rehab services. The services needed could be arranged by the patient's physician to be provided at another level of care, such as level 1.  

Subacute rehabilitation is typically a short-term program that includes at least 3 hours of therapy per day, with therapy occurring at least five days a week for more than one week. Duration can also range from a few days to several weeks and sometimes over three months. Current medical literature notes that perinephric abscess is usually a complication of a urologic infection which results from fat necrosis. This condition is usually a combination of urologic infection that can occur through the management or spread of infection from a focus outside the kidney or local spread of a related urologic infection. Treatment for these conditions can include antibiotic therapy and even surgical intervention in cases when a perinephric abscess is unsuccessfully treated with antibiotic therapy and percutaneous catheter drainage.  

Based upon the provided documentation, the patient did not meet criteria for level 3 subacute rehabilitation stay. His needs could have been effectively met at level 1 subacute rehabilitation. While it was noted that he was receiving IV antibiotics to treat his renal abscess, he had not received therapy at least 3 times a day 5 days a week throughout the entire duration of his stay. This indicates that he did not require Level 3 care. The level 3 subacute rehabilitation stay was not considered medically necessary for this patient.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Level 3 Subacute Rehabilitation Stay not substantiated.