Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Resp Failure S/P [status post) Trach

Treatment continued acute rehabilitation services 

The insurer denied coverage for continued acute rehabilitation services 

The denial is overturned

This patient has a history of Juvenile Myoclonic Epilepsy who was admitted to hospital status post (S/P) Cardiac arrest. The patient had a prolonged acute hospitalization for Anoxic Encephalopathy. The patient had Resp Failure S/P Trach. The patient was in a vegetative state and subsequently transferred to an acute rehab facility.

As per Review of records and medical doctor (MD) letter, the patient's initial status was he was in a vegetative state but started communicating nonverbally with head gestures soon after admission. He emerged from minimally conscious state to fully conscious state by second week of admission. The patient's progress has been fluctuating because of his respiratory status but has been trending up overall. The patient is requiring 24-hour skilled therapy from Respiratory therapists and receiving multiple evaluations by MDs throughout the day.

The patient has copious secretions in the respiratory tract which need to be suctioned multiple times during the day. The patient receives aggressive pulmonary toileting with cough assist device, gets Nebulizer treatments, Tobi inhalations. The patient has been tolerating Passy Muir speaking valve (PMV) during therapy hours.  Also, he demonstrated ability to read, comprehend and spell with a head laser and alphabet board which is a marked improvement.  Physical therapy (PT) and occupational therapy (OT) therapists are managing his spasticity and dystonic posturing in the upper and lower extremities with positioning, stretching, and splinting. Patient also receiving Botulinum Toxin into bilateral (B/L) upper extremities followed by casting to improve ROM (range of motion) and prevent contractures and skin breakdown.

The patient's computed tomography (CT) also revealed some suggestion of hydrocephalus for which NS (neurosarcoidosis) has been consulted to discuss VP (ventriculoperitoneal) Shunt placement.

His MDs are recommending another week in therapy to optimize his respiratory status and establish a respiratory care routine which can be followed discharge (DC) from Rehab hospital to avoid risk of pneumonia and other respiratory emergencies. The patient is tolerating PMV and also Trach Capping is being done along with further weaning off from O2 (oxygen). Speech-language pathologists (SLP) is working to improve swallowing function for better management of oral secretions to decrease risk of aspiration pneumonia (PNA). Spasticity management is also being optimized. They are also working on optimizing his communication system so that patient can potentially direct his own care.  Therapy is also working on continued verticalization and training of family for safe DC to home.

His MDs are recommending another week in therapy to accomplish this. This patient has had a remarkable recovery from his vegetative state to current state and it is appropriate to stabilize these hard achieved gains by continuing therapy for one more week as requested by his treating physicians and therapists.

Based on above it is appropriate to continue patient in therapy.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for continued acute rehabilitation services. Medical Necessity is substantiated.