Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma-Brain Injury. 
Treatment: Acute Inpatient- Rehabilitation Center. 

The health plan denied the continued stay at the acute rehabilitation center as not medically necessary. 
The reviewer has upheld in whole the health plan's determination. 

The patient  has a diagnosis of "multiple injuries after hurting self," polysubstance abuse (9-month substance abuse rehab, 3 prior psychiatric hospitalizations, 2-3 prior suicide attempts), and possible attention deficit hyperactivity disorder (ADHD). The patient's medical records indicate that the patient was admitted after a fall out of a 4th floor window. Glasgow Coma Scale (GCS) was 10 at the time of transport. The patient had skull, sternal, and left iliac crest fractures. A computed tomography (CT) scan of the head showed a large left frontal fracture with associated epidural, subdural, subarachnoid and intraparenchymal hemorrhage. The subdural hematoma increased in size and the patient underwent right sided cranioplasty and underwent intubation and tube feeds. He progressed to extubation and oral (po) intake and had treatment with multiple antibiotics. The patient was treated for both central fevers and upper motor neuron syndrome. The fall was thought to be a possible suicide attempt, and the patient had a positive toxicology screen for alcohol and stated to the hospital staff that he had taken Xanax. He was followed by psychiatry during his stay. The patient had a neuropsychological evaluation indicating moderate weakness on processing speed, attention switching, working memory, learning/memory which were attributed to the traumatic brain injury and his suspected ADHD. 

Per the discharge summary the patient was accepted by the CARES (Collaborative Assessment, Response, Engagement & Support) program for Comprehensive Adolescent Rehabilitation and Education Services. He had appointments for intake and was accepted and awaiting placement. On this date speech, occupational, and physical therapy outpatient were not recommended as they were not required at the time. 

Based on the available documentation and the diagnosis being treated, continued stay in the acute rehabilitation center is not medically necessary to achieve important health and functional goals. A letter provided clarification on the type of care provided and states it is best characterized as a Long-Term Acute Care hospital. This level of care is not medically necessary for the dates in question. The patient's physician documented in the discharge summary that the patient did not require speech, occupational, or physical therapy. For a patient who does not need speech, occupational, or physical therapy, acute rehabilitation is not the appropriate level of care. The patient requires ongoing care for his complex psychiatric illness, substance abuse, and sequelae of traumatic brain injury but these are not medically necessary to be provided in the inpatient care setting at the acute rehabilitation center. 

A letter was received from the patient's family where the author indicates that discharge planning was not conducted in a timely manner based on the letter writer's recollection of the items discussed at meetings and discussions with the facility staff.  All patients require a safe discharge plan but delay by the facility in planning discharge does not change the medical necessity of the treatment. The delay in planning discharge does not change the determination of medical necessity for the days in question.