Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Numerous complex acute and chronic medical
problems
Treatment: Continued Acute Inpatient Rehabilitation Care
The insurer denied the Continued Acute Inpatient Rehabilitation Care.
The denial is overturned.

The patient is a female child with complex medical history significant for cerebral palsy, chronic lung disease status post tracheostomy tube placement with ventilator dependence, feeding intolerance status post gastrostomy tube placement and dependence, gastroesophageal reflux with recurrent aspiration pneumonia status post Nissen fundoplication, seizure disorder on multiple anticonvulsant medications, autonomic dysfunction, failure to thrive, and global developmental delay. She has been hospitalized in the past for aspiration pneumonia, acute respiratory failure, and status epilepticus. In between acute hospitalizations, she has been admitted to Blythedale for ongoing management of acute respiratory failure with slow ventilator weaning, comprehensive rehabilitation as able, and family teaching. She has been on the waiting list for a long-term skilled nursing care facility pending her parents' ability to learn all of her care. She was most recently readmitted from a three-week acute care stay for management of an acute respiratory exacerbation with severe atelectasis.

While in acute care, the patient was experiencing seizures. MRI (magnetic resonance image) revealed extensive bilateral polymicrogyria, pontine hypoplasia, and mild inferior vermian hypoplasia, similar to previous MRI (magnetic resonance image) findings. Rufinamide was added to her anticonvulsant regimen. She received aggressive airway clearance with albuterol, Vest and cough assist, and hypertonic saline for mucolysis. Following return to Blythedale, she was noted to have hypoventilation, with adjustments made in her ventilatory support, now with slowly weaning rate. She remains on Vest and cough assist twice daily for airway clearance. She has required adjustments to her glycopyrrolate dosing to help manage secretions. She receives all feedings via gastrostomy tube.

In terms of therapeutic intervention, the patient receives range of motion exercises to the upper extremities with application of splints as able. She receives range of motion exercises to the lower extremities, limited by contractures and neuromuscular scoliosis. She uses a Tobii eye gaze device, unclear if she is aware of cause and effect. She currently receives Occupational Therapy three times weekly for 15 minutes, Physical Therapy three times weekly for 30 minutes, and Speech Therapy twice weekly for 30 minutes, all as her clinical situation allows. The overall goal of all therapeutic intervention is to prevent regression and further contracture while advancing her functional skills to the best of her ability. There is no indication that her family has been able to complete all necessary teaching required to take her home.

Yes, the Continued Acute Inpatient Rehabilitation Care is medically necessary.

This female child suffers from a number of complex acute and chronic medical problems, as described above. She has been transferred back and forth between acute care and Blythedale Children's Hospital, where she receives comprehensive medical care and rehabilitation services. In December, she was placed on the waiting list for long-term care placement pending successful family teaching. From the date in question, while awaiting final disposition, she has continued to receive around-the-clock skilled nursing services, physician oversight, aggressive respiratory care including slow ventilator weaning, rehabilitation services to prevent regression and facilitate range of motion, and family teaching and support. Taking into consideration the complexity of her medical condition, these comprehensive interventions are not consistent with subacute care and are most consistent with acute inpatient rehabilitation, medically necessary.

The recommended length of approval is 16 weeks with re-evaluation for continued medical necessity at that time.