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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for acute inpatient hospital level of care that includes a sitting program, wound care, fluids for blood pressure stabilization, physical therapy, intravenous (IV) Toradol, and intravenous immunoglobulin (IVIG) therapy. The records provided for review do not demonstrate that the requested acute inpatient hospital level of care with a sitting program, wound care, fluids for blood pressure stabilization, physical therapy, IV Toradol, and IVIG therapy are medically necessary for treatment of this patient. Although the patient will require some of these interventions on a long-term basis, the documentation suggests that the services can be provided in the outpatient setting. The patients medical history is significant for NMO, neurogenic bowel and bladder, multiple decubiti, recurrent urinary tract infections, and depression. The provider noted that the patients trochanteric/sacral/upper back ulcer has appropriate healing with anticipation of full healing by the following week. Complex wound care management, coupled with aggressive interventions aimed at preventing complications and prevention of new wounds, is expected to be needed for a prolonged period of time, and can be provided on an outpatient basis. The requested fluids for blood pressure stabilization, IV Toradol and IVIG are not required in the acute inpatient setting. The patients recent laboratory blood test abnormalities require additional intermittent monitoring and potential treatment. However, none of the laboratory abnormalities requires imminent treatment in the acute hospital setting. The patients recorded vital signs were consistently stable with the reported availability of midodrine to prevent symptomatic low blood pressure related to autonomic issues. The patients NMO has been treated with approximately monthly IVIG and supportive care. The patients condition is likely to require these ongoing interventions, which can be provided as an outpatient. Further, the patient does not require formal physical therapy in the acute inpatient hospital setting. The submitted records indicate that the patient required therapist-directed rehabilitation focused on maximizing function and independence along with the patients ongoing treatments. All told, the records do not demonstrate that the patient requires acute inpatient level of care. Therefore, the requested acute inpatient hospital level of care that includes a sitting program, wound care, fluids for blood pressure stabilization, physical therapy, IV Toradol, and IVIG therapy is not medically necessary for this patient.Final Result: The reviewer determined that the requested services 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 internal medicine with subspecialty certification in hospice and palliative medicine 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.