Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Hypoxic respiratory failure.
Treatment:  Acute Inpatient Rehabilitation.

The insurer denied the Acute Inpatient Rehabilitation.  The denial is overturned. 

The patient is a male with history of pneumonia with hypoxic respiratory failure after accidental overdose.  He developed encephalopathy status post intubation, ventilation, on PEG (percutaneous endoscopic gastrostomy)-tube feeding.  He was admitted.

CT (computed tomography) scan of the brain showed hypotenuse areas pointing to possible acute infarcts.

Prior to admission, the patient was independent living by himself in a trailer home. On discharge, he will be going to stay with his father.

The patient was admitted to acute inpatient rehabilitation. 

Yes, based on the medical records, transfer to acute inpatient rehabilitation is medically necessary

The patient has met all the criteria for acute rehabilitation care INTERQUAL Criteria 2020 for Acute Rehabilitation.  He was admitted to acute inpatient rehabilitation.  He was dependent but participatory in PROM (passive range of motion) PT (physical therapy), SLP (speech-language pathology) and OT (occupational therapy), but not getting full Traumatic Brain Injury Rehabilitation and Cognitive stimulation that will help his recovery.

The patient has met all the Interqual requirements for an acute inpatient rehabilitation as follows:  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); 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, he will qualify for a Traumatic Brain Injury rehabilitation with cognitive stimulation; 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 has many ongoing acute medical issues that require further stay in acute inpatient rehabilitation; 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, he has been participating in PT (physical therapy); 5) The patient's cognitive status does not inhibit active participation in therapies as he will also need cognitive stimulation to help the rehabilitation process; 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 that is needed based on his current status is not available at a lower level of rehabilitative care, the SNF (skilled nursing facility) or custodial care; and 7) The services will be restorative and less of maintenance or custodial nature and the patient is more likely to benefit rehabilitation at the acute rehabilitation level of care due to his current level of participation in rehabilitation and the need for specialty Traumatic brain Injury rehabilitation with Cognitive stimulation.

As stated above, the transfer to acute inpatient rehabilitation is medically necessary with clinical evidence showing that stay in IRF (inpatient rehab facility) is reasonably expected to be health beneficial for the patient, and/or withholding it, in whole or in part, will reasonably be expected to affect the patient's health adversely based on his medical circumstance.