Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Ventilator dependent respiratory failure.
Treatment:  Continued inpatient rehabilitation stay.

The insurer denied coverage for the continued inpatient rehabilitation stay.  The denial is upheld. 

This is a male patient with a past medical history of type 2 diabetes mellitus.  The patient was admitted to inpatient rehabilitation from an outside facility for management status post mechanical ventilator, tracheostomy, and percutaneous endoscopic gastrostomy (PEG) tube insertion, and ventilator dependent respiratory failure (VDRF).  

The patient's PEG tube feedings were on hold, as the PEG tube was not in place. There were no recent hypoglycemic episodes. The patient was to be treated with Lantus dose 14 units once tube feedings were resumed.  The patient had renal failure, as per nephrology, and was on hemodialysis.  The patient also was status post COVID-19 and had chronic anemia.  A secondary note indicated that the patient was admitted with VDRF and cryptococcal fungemia.  The patient was undergoing a gastrointestinal consultation for the evaluation of PEG tube following Computed Tomography (CT) of the chest, which included a reading that possibly the PEG tube bumper was not in the gastric lumen, although the tube lumen was in communication with the gastric lumen.  An interdisciplinary progress note indicated the patient remained on a ventilator on assist control and was poorly responsive.  There had been no significant change.  His prognosis was guarded.  A progress note revealed the patient was awake, alert, responsive, and in better spirits.  The patient was stable.  He had developed clostridium difficile colitis and was under treatment.  The patient was to continue with current treatment. 

Per Milliman Care Guidelines (MCG), an inpatient rehabilitation stay requires documentation of patient status supporting active participation in, and benefit from, intensive therapy at least 3 hours per day for 5 days per week and therapy at least 15 hours per week (7 consecutive days).  MCG also indicates that a Long-Term Acute Care Hospital (LTACH) stay is supported, if it is more appropriate than other levels of care (e.g., skilled nursing facility, home healthcare), as indicated by ventilator and respiratory management needed beyond capabilities of alternative levels of care, clinical management needed beyond capabilities of alternative levels of care, frequent diagnostic services needed, including clinical assessment, laboratory, and imaging, more intensive skilled services (e.g., specialty nursing care, onsite physician assessments) needed than available at lower level of care, or lower level of care has failed (e.g., patient readmitted to acute care from lower level of care).

In this case, the patient is dependent on mechanical ventilation.  The records do not support active participation in therapy or that care could not be provided at a lower level.  As such, the continued inpatient rehabilitation stay is not considered medically necessary for this patient. 

As the patient was on a ventilator, there was insufficient support for that particular level of care.  In addition, the social worker's note reported that other facilities, such as nursing homes, had been contacted, but requests were denied secondary to out of network, no beds, etc.  However, this supports that the patient could have been treated at a lower level of care.  The note mentions that, per a medical provider, the patient was "stable to move to the next level of care pending accepting facility."  Another note indicated the patient was accepted by a nursing home.  Therefore, the records did not support continuation of stay at an LTACH/inpatient rehabilitation.  

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for the continued inpatient rehabilitation stay is not substantiated.  The insurer's denial is upheld.