Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right intraparenchymal hemorrhage due to a ruptured arteriovenous malformation
Treatment: Continued rehabilitation stay
The insurer denied the continued rehabilitation stay.
The determination is overturned.

The patient had significant neurologic injury following a right intraparenchymal hemorrhage due to a ruptured arteriovenous malformation (AVM) status post craniotomy followed by embolization and aggressive neuroprotective measures. During her acute hospital stay, she was treated for right lower lobe pneumonia, feeding intolerances, opiate withdrawal, and transaminitis. She was transferred for comprehensive rehabilitation. Notable improvements include the following: initially with left sided hemiparesis unable to move her left arm and had on admission, eventually developing the ability to lift her left arm overhead, open her fingers, and extend her wrist against gravity; participation in school activities during the day, with only mild inhibition weaknesses, expected to return to her prior school following discharge; weaning completely from opiates and benzodiazepines; tolerating a regular diet with thin liquids and no need for supplementation at home; and remaining seizure free on no anti-convulsant medications. She made excellent functional gains and was transferred to the day hospital program to continue rehabilitation. At issue is the medical necessity for the continued rehabilitation stay.

The acute rehabilitation stay was medically necessary and appropriate. This left-hand dominant child suffered a right-sided intraparenchymal hemorrhage due to a ruptured AVM, with resultant left-sided hemiparesis and facial weakness. She was aggressively managed in the acute hospital and was transferred for ongoing aggressive rehabilitation to recover as much function as possible. She had been making excellent progress, with steadily improving left-sided function including improvements in left hand function, but with ongoing left-sided neglect, still far from fully functional. She was continuing to show gains with intensive therapies. She was able to ambulate 200 feet albeit with fatigue. She was able to ascend and descend one flight of stairs with minimal assistance and verbal cues. She demonstrated improved attention to tasks and was able to use her right arm to write sentences with good legibility. Performance on standardized testing revealed mild weakness in attention/inhibition with some impulsivity. Overall, this child made excellent progress following a potentially devastating injury. Although there are limited physician progress notes for the period of time in question, there are rehabilitation notes from all days in question. It was noted by therapy that despite fantastic gains, she continued to have some left-sided neglect and she was not yet able to functionally return to her home in terms of ambulation and stairs. As a previously left-handed child, she needed to adapt to right-handed activities including writing. She was also building endurance during the latter days so that she could successfully navigate her environment safely at home. She was working on transitions, sitting to standing and the reverse. The family was actively engaged so as to maintain her safety and progress once discharged. With these devastating injuries, it is essential to make use of the potential for rapid progress early in the recovery period. This is when rewiring can occur and adaptations can be made. This is something best achieved with aggressive inpatient rehabilitation. Outpatient therapy is not sufficiently intensive to facilitate these types of gains. 

Ruptured AVM is a potentially neuro-devastating condition, requiring aggressive management both acutely as well as in rehabilitation. With such aggressive rehabilitation as can occur in specialized pediatric rehabilitation institutions, these patients have the potential for near-complete recovery and return to typical life. Based on the documentation provided, the continued hospital stay was medically necessary and appropriate, consistent with the current literature and standards of care.