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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for all or any long-term acute care hospital (LTACH) - intensive care unit (ICU) services. Barker-Davies and colleagues report that while long-term sequelae of COVID-19 are unknown, evidence from previous novel coronavirus outbreaks demonstrate impaired pulmonary and physical function, reduced quality of life, and emotional distress. The authors further report that rehabilitation of COVID-19 survivors requiring critical care who may develop psychological, physical and cognitive impairments should be tailored to individual patient needs.  Barlow and colleagues note that there is currently no widely accepted standard of care in the pharmacologic management of patients with COVID-19. Treatment is largely supportive, including management of symptoms and respiratory failure. Early rehabilitation is appropriate and necessary as a general measure on an empiric basis, particularly in the setting of severe respiratory infection, severe functional impairments and prolonged hospital stays. Depuydt and colleagues note that long-term survival in patients discharged from the ICU with tracheostomy and ventilator dependency after failure to wean was not significantly different from that of patients with tracheostomy and weaned at ICU discharge. In this case, the patient became acutely ill with COVID-19 along with other comorbidities. They required intubation and mechanical ventilation for respiratory failure and had a prolonged acute hospital course with several complications. They failed multiple weaning trials while hospitalized and was subsequently transferred to a LTACH for further care, including ventilator management, ventilator weaning trials and rehabilitation. They were otherwise largely medically stable, with stable vitals and laboratory test results. The care the patient received, including tube feeds, routine medication administration, and incontinence care, is/was custodial in nature. LTACH level of care is intended for patients requiring prolonged care that is medically complex and usually involves multiple services at a high acuity level including treatment such as chest tubes, extensive wound care, stable cardiac drips, multiple intravenous antibiotics, hemodialysis/peritoneal dialysis, prolonged intravenous therapy, total parenteral nutrition, tracheostomy care/extensive pulmonary services, ventilator weaning, and frequent imaging/lab testing. Given that this patients care can be handled at lower levels of care such as inpatient rehabilitation facilities, skilled nursing facilities, or custodial facilities, the services at issue were not and are not medically indicated. Therefore, LTACH - ICU level of care was not and is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are 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.