Appeal type: Medical necessity
Decision: Overturned

Diagnosis: s/p (status post) CVA (cerebrovascular accident).
Treatment: Continued Acute Inpatient Rehabilitation (AIR) Hospital Setting .
The insurer denied the Continued Acute Inpatient Rehabilitation (AIR) Hospital Setting.
The denial is overturned. 

The patient is a male with history of CVA (cerebrovascular accident) with large Right intra-cerebral hemorrhage with intraventricular hemorrhage complicated by hydrocephalus and subarachnoid hemorrhage secondary to a ruptured Right Posterior Communicating Artery aneurysm with subsequent coiling and embolization.

The patient's hospital course was complicated by many medical issues including seizures, DVT (deep venous thrombosis) status post IVC (inferior vena cava) Filter, later status post VP (ventriculoperitoneal)-shunt. All of these were affecting his cognition, with aphasia, dysphagia, left hemiplegia, anemia requiring transfusion, urosepsis requiring IV (intravenous) antibiotics, etc.

Prior to admission, the patient lived with family in an apartment and was independent with ADLs (activities of daily living) and independently ambulating.

The patient was admitted to Acute inpatient rehabilitation. He was impulsive, on advanced mechanical diet with thin liquid, ambulating propelling wheelchair using lower extremity for 100 feet with minimum assistance, minimal assistance/supervision for toileting, transfer, upper body dressing/bath, lower body dressing/bath.

The patient is high risk falls while unsteady on his feet.

Yes, the Continued Acute Inpatient Rehabilitation (AIR) Hospital Setting was medically necessary.

The patient met all the criteria for acute rehabilitation care INTERQUAL Criteria for Acute Rehabilitation. He was impulsive, on advanced mechanical diet with thin liquid,  ambulating propelling wheelchair using lower extremity for 100 feet with minimum assistance, minimal assistance/supervision for toileting, transfer, upper body dressing/bath, lower body dressing/bath. He is high risk falls while unsteady on his feet. He was also able to follow commands and also fully motivated.

The request for acute inpatient rehabilitation is due to deconditioning from bed rest. He has been actively participating in PT (physical therapy) while under acute admission. The plan is to discharge home to live with family.

The patient has met the Interqual requirements for continued acute inpatient rehabilitation by the following:

1) A patient who needs a comprehensive and integrated rehabilitation program that requires a multi-disciplinary, coordinated team approach. In this instance, the patient as stated above requires SLP (speech language pathology), PT (physical therapy) and OT (occupational therapy). He was independent with ADLs (activities of daily living) prior to admission, and he was currently limited due to deconditioning with increased risk of falls. 2) A patient who requires and can perform at least 3 hours per day of therapy at least 5 days per week. In this instance, in SLP (speech language pathology), PT (physical therapy) and OT (occupational therapy) participation, the patient was already showing motivation and participating in therapy sessions while following commands. 3) The patient may also have co-morbidities that require close supervision and 24-hour availability by the appropriate type of physician. In this instance, the patient does have co-morbidities, including DVT (deep venous thrombosis, that do require close supervision by a physician in an acute rehabilitation setting. 4) The patient must have a high level of endurance, and rehabilitation potential with significant measurable improvement demonstrated within a reasonable period of time. In this instance, the patient has status as stated above that does require such level of continued intensive rehabilitation. 5) The patient's cognitive status does not inhibit active participation in therapies. In this instance, he is able to follow command and participate. 6) The services are not available in outpatient setting. In this instance, the level of SLP (speech language pathology), PT (physical therapy) and OT (occupational therapy) rehabilitation needs are not available in outpatient setting with required level of intensity that is available at acute inpatient rehabilitation setting. 7) The services are more restorative and not of maintenance or custodial nature and the patient is more than likely to benefit from a 3 hours/day of intensive/comprehensive rehabilitation, as stated above.

The patient met all the INTERQUAL requirements, as stated above, and therefore there is clinical basis for continued stay in an acute inpatient rehabilitation unit, as his needs could not have been met at a lower level of care. He is high-risk for falls and there is a need for him to be able to maintain adequate balance with lower risk of falls.

The patient was more likely to benefit from a continued intensive rehabilitation program to restore him to his independent status.