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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement, authorization and coverage for acute rehabilitation services provided from 10/17/18 forward. Per Gajofatto and colleagues, primary progressive multiple sclerosis is characterized by continuous disability worsening from the onset, with no disease-modifying therapy currently proven to favorably impact its course and outcomes. Beer and colleagues note that the mainstays of treatment include managing symptoms and maximizing function through rehabilitation interventions, including energy conservation and compensatory measures. Intensive and aggressive exercise are frequently not tolerated and can be counterproductive.In the present case, the enrollee is reported to have primary progressive multiple sclerosis. He has had an episode of severe medical illness due to sepsis related to a scrotal injury and meninoencephalitis of unclear etiology. His acute hospital course was complicated. After medical stabilization, he was transferred to acute inpatient rehabilitation on 10/4/2018. He presented to acute rehabilitation with fatigue, mild cognitive impairments and a profound change in functional status versus his baseline. As of 10/17/2018, he had made relatively modest progress in a few areas of basic self-care and mobility, but remained at a functional status where significant assistance was still required for bed mobility and transfers. He was ambulating nonfunctionally for very short distances at the parallel bars, requiring significant assistance.Based on the recovery course to date, a protracted convalescence would have been expected for this patient. This would have included rehabilitation provided over a significant period of time, likely several months. Rehabilitation would have been appropriate to effect an early transition to the community, provided the plan for treatment accounted for the patients diagnoses and current condition. This type of rehabilitation would have incorporated measures such as manual and power wheelchair training, family training (especially for transfers), durable medical equipment training procurement, ramp placement in the home, etc. No significant difference in clinical course or outcomes would otherwise have been expected with ongoing acute inpatient rehabilitation versus rehabilitation provided at a skilled nursing facility. Intensive rehabilitation aimed at restoring his functional status close to his premorbid baseline through higher volumes of exercises and functional activities would not have been expected to favorably impact his course, as this recovery would primarily have been time-dependent.  Overall, the enrollee had risks of complications due to his underlying disease and conditions, but he had been medically stabilized and there were no longer any documented ongoing conditions requiring high frequency inpatient physician supervision and care. Therefore, acute rehabilitation services from 10/17/18 forward were not and are not medically necessary for this patientFinal Result: The reviewer determined that the requested services were not and are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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.