Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke, intracerebral hematoma.
Treatment: Continued Subacute Rehabilitation Stay.
The insurer denied the continued subacute rehabilitation stay. The denial is upheld. 

The patient is a female. She has a past history of hypertension, COPD (chronic obstructive pulmonary disease), diabetes and depression.  Her baseline is independent and living in the community with her roommate/significant other in an elevator-accessible apartment with three steps to enter.  She was a community ambulator without an assistive device at baseline.  She was reported to be the "caretaker" for her roommate/significant other.
	
The patient sustained an acute stroke, complicated by development of a right frontoparietal intracerebral hematoma.  She underwent craniotomy with evacuation.  Postoperative imaging demonstrated near complete evacuation of the right frontoparietal intracerebral hematoma.  There was residual left hemiplegia and aphasia.

The patient was transferred to a subacute inpatient rehabilitation facility for further care.  She participated in multidisciplinary therapies.  She was oriented times 3.  She was moderate assist for feeding.  She was largely total assist for other self-care and mobility.

The patient had just started gait training.  She was ambulating five feet at the parallel bars with max assist of two.

The patient was requiring moderate assist for transfers.  She was ambulating five feet at maximum assist.  She was requiring supervision for feeding.  She was requiring contact guard assist for upper body dressing.  She was requiring minimum assist for lower body dressing.  She was requiring minimum assist for toileting.

The patient was requiring minimum assist for transfers.  She was ambulating 25 feet at maximum assist.  She was requiring stand by assist for upper body dressing.  She was requiring minimum assist for lower body dressing.  She was requiring minimum assist for toileting.

The physician's encounter; the patient was noted to have no headaches.  She had non-radiating back pain, left shoulder pain and persistent left hemiplegia.  Lab test results were stable.  Her medications included blood pressure pills, a statin and subcutaneous heparin.

The patient was on a chopped solids with thin liquids oral diet with no added salt and no concentrated sweets.

The patient was requiring minimum assist for transfers.  She was ambulating 40 feet at moderate assist.  She was requiring stand by assist for upper body dressing.  She was requiring contact guard assist for lower body dressing.  She was requiring minimum assist for toileting.  The long-term plan was returning to the community to her prior residence.  

The patient was requiring minimum assist for transfers.  She was requiring set up for feeding.  She was requiring contact guard assist for lower body dressing.  She was requiring minimum assist for bathing and toileting.

The patient was requiring minimum assist for transfers.  She was ambulating 40 feet at moderate assist.  She was requiring set up for feeding.  She was requiring contact guard assist for lower body dressing.  She was requiring minimum assist for bathing and toileting.

No, the Continued Subacute Rehabilitation Stay at Level II is not medically necessary.

The records in the present case indicate that the patient sustained a stroke with complications resulting in severe to profound functional deficits relative to her baseline of full independence.  She underwent inpatient rehabilitation at the subacute intensity level for a prolonged period of time but was making very slow progress.  She only started ambulating minimal amounts, after about one and a half months at the facility.  She was making very slow progress subsequently.  

The patient was ambulating very short distances, but requiring significant levels of assistance to do so, rendering her ambulation nonfunctional.  There were no indications that she was working on mobility using a wheelchair.  She was otherwise making minimal gains with her self-care functionality over a prolonged period of time.  

After almost three months at the subacute inpatient rehabilitation facility, the patient was continuing to require physical assistance for her transfers and lower body self-care.  There were no reasonable indications that she would become independent and safe with her self-care or mobility for the foreseeable future within a reasonable and predictable period of time.  No disposition planning was otherwise in place.  Notably, it was noted that she was the "caretaker" for her roommate/significant other premorbidly.  No in-person family or caregiving training was documented.  There were no ongoing medical or nursing needs requiring ongoing skilled services.  The need for further subacute rehabilitation level care is not supported by the available records.  Further care could have been provided in a lower level of care setting.