Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia. 
Treatment: Continued Stay at an Acute Rehab Facility. 

The insurer denied the Continued Stay at an Acute Rehab Facility. 
The denial is upheld. 

The patient is a female with history of pneumonia with hypoxic respiratory failure
after COVID (coronavirus disease) infection. She is status post intubation and DVT
(deep venous thrombosis). She was admitted in the spring. She has stage 3 sacral
ulcer. 

Prior to admission, the patient was independent living by herself. On discharge, she
will be going to stay with her daughter. The patient was admitted to acute inpatient rehabilitation. A month later, she was modified independent with Activities of Daily Living, including bed mobility, requiring transfers, toilet and upper/lower body dressing, while ambulating with no Assistive Device under supervision and able to navigate 12 steps x 3. The plan was to discharge her home, but this was changed to later in the month for wound care. 

No, the Continued Stay at an Acute Rehab Facility was not medically necessary. 

The continued acute inpatient rehabilitation was not medically necessary, because
the patient has not met all the criteria for acute rehabilitation care INTERQUAL
Criteria for Acute Rehabilitation. She was admitted to acute inpatient
rehabilitation and a little less than a month after admission she was modified
independent with Activities of Daily Living, including bed mobility, requiring
transfers, toilet and upper/lower body dressing, while ambulating with no Assistive
Device under supervision and able to navigate 12 steps x 3. The plan was to
discharge her home, but this was changed to the end of the month for wound care. 

The patient has not met all 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 PT (physical therapy) and OT (occupational
therapy) and she has been modified independent with ADLs (activities of daily
living) at original date of discharge. 
2) A patient who requires and can perform at least three hours per day of therapy at
least five days per week. In this instance, the patient has been modified
independent with ADLs (activities of daily living) as of original date of
discharge. 
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 no ongoing acute medical issues that require further stay in acute inpatient
rehabilitation, because the wound care can continue at a lower level of care.
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, she has been modified independent with ADLs
(activities of daily living) as of original date of discharge and she can meet any
further needs for rehabilitation at a lower level of care. 
5) The patient's cognitive status does not inhibit active participation in therapies. In
this instance, she has been modified independent with ADLs (activities of daily
living) as of original date of discharge. 
6) The services are not available in outpatient setting. In this instance, the level of
PT (physical therapy) and OT (occupational therapy) rehabilitation that is needed
based on her current status is available at a lower level of rehabilitative care. 
7) The services are less restorative and more of maintenance or custodial nature
and the patient is less likely to benefit rehabilitation at the acute rehabilitation level
of care due to her current level of participation in rehabilitation. 

Therefore, given the above, and given that the Interqual guidelines are reasonable
and generally accepted in the rehabilitation community, the Continued Stay at an
Acute Rehab Facility was not medically necessary. 

As stated above, the continued stay in acute inpatient rehabilitation was not
medically necessary, with clinical evidence above showing improvement that further
stay in IRF (inpatient rehabilitation facility) is not reasonably expected to be health
beneficial for the patient, and/or withholding it in whole or in part would not be
reasonably expected to affect the patient's health adversely. She has been modified
independent with ADLs (activities of daily living) as of original planned date of
discharge.