Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient sustained a stroke, which affected his motor and sensory systems on the left side. He has been treated with outpatient therapy since August 2016, which has included therapeutic exercise, therapeutic activities, and neuromuscular re-education. From August 2016 to December 2016, the patient attended therapy that was aimed at decreasing his impairments, improving left-sided motor control, and improving his overall functioning. The patient was noted to be less fearful using his left lower limb for tasks such as standing in the kitchen and dressing himself. Decreased left shoulder tightness and inconsistent improvements in active assisted shoulder flexion were noted. There had been no improvements in active movements of his left hand. His left hand was tight, and he was not consistently wearing his left wrist-hand orthosis. The patient has requested reimbursement for additional five hours of gait therapy (beyond the approved one hour) provided on 8/8/16, 8/9/16, 8/20/16, 8/21/16, 8/27/16, 8/28/16, 9/1/16, 9/2/16, 9/12/16, 9/29/16, 9/30/16, 11/7/16, 11/8/16, 11/9/16, 12/28/16, and 12/29/16; additional 11 hours of gait therapy (beyond the approved one hour) provided on 8/10/16, and additional 30 minutes of gait therapy (beyond the approved one hour) provided on 8/22/16, 8/23/16, 8/24/16, 8/25/16, 8/26/16, and 10/7/16. The Health Plan denied the requests and reported the services at issue were not medically necessary for the treatment of this patient. At issue is whether the requested additional 5 hours of gait therapy (beyond the approved one hour), additional 11 hours of gait therapy (beyond the approved one hour), and the additional 30 minutes of gait therapy (beyond the approved one hour) on the dates specified above as requests for reimbursement, were medically necessary for the treatment of this patient. Functional impairments due to acquired brain insults such as stroke can be profound. Some recovery is expected with time, and many of these impairments are amenable or addressable by compensatory measures and directed rehabilitation efforts. Standard of care for this condition would include rehabilitation services, first in the inpatient setting if necessary, followed by rehabilitation in the community setting if still indicated, based on impairments and the potential for achieving practical and functional goals. Most of the significant neurological and functional recovery following a stroke occurs in the early stages after stroke (within the first 30 days to 3 months after the stroke), and gains are slower to come in the subsequent year. Rehabilitation efforts are not indicated indefinitely if they are not reasonably expected to positively impact clinical outcomes, even if there are significant and persistent residual deficits. In this case, the patient sustained a stroke at an unspecified time. This is of significant importance in determining prognosis and amenability to rehabilitation efforts. The available medical records do not address this issue. There is a lack of documentation regarding the services provided on the dates of service in question. Only a brief, general summary of the services rendered during the period in question was provided. There is no documentation of appropriate indication for therapy during this time period, or objective benefit that is reasonably attributable to the services in question. While the patient had impairments, functional deficits, and risks for complications during this time period and afterwards, there is insufficient documentation provided to support the necessity of the services rendered or that these services mitigated his risks for complications to a clinically significant degree. The medical evidence does not support the services at issue in this clinical setting. Therefore, the additional 5 hours of gait therapy (beyond the approved one hour) provided on the dates specified above, additional 11 hours of gait therapy (beyond the approved one hour) provided on the date specified above, and additional 30 minutes of gait therapy (beyond the approved one hour) provided on the dates specified above were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.