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

The patient is a 30-year-old male who was noted as of 3/23/03 to be in a vegetative state. He was responsive to noxious stimuli. He had no eye opening and followed no commands. Per the physicians note of 4/12/03, the patient had spontaneous eye opening, was non-verbal, and had increased tone in all four extremities. Upon admission to an eight-week coma rehabilitation program on 4/22/03, the patient exhibited the following: spontaneous eye opening, no tracking, disconjugate gaze, inability to follow directions, decorticate posturing on the left side, decerebrate on the right side, and no spontaneous motor movement. The patient was returned to acute care on 5/2/03 for repair of a colon perforation and returned to rehabilitation on 5/9/03. He remained at the same level of functioning. As of 7/16/03, there was no change in the patients condition. He was transferred to Care Meridian Marin on or about 7/18/03. The submitted notes further indicate the patient began using his right upper extremity voluntarily to follow commands in early August 2003. He made very gradual progress; at times he was able to follow commands while at other times he was vegetative. By 9/15/03, the patient was following simple commands more reliably (e.g., squeeze hand, open mouth, etc.). A rehabilitation evaluation performed on 8/02/04 indicated the patients trach tube was out and stoma was closed. It was further noted the patient was oriented x 1 and was starting to follow multiple step commands with cues. He needed moderate assistance to stand and transfer, and moderate to maximum assistance to ambulate 300 feet.  The patients balance and attention had decreased and he had increased spasticity. The patient had been in rehabilitation from 5/04/04 through 8/16/04 following an Achilles tendon release, which resulted in a decrease in cognitive and functional skills. He was subsequently discharged to his fathers home. The patient underwent further evaluation on 8/30/04. At that time, the patient required moderate assistance for bed mobility, maximum assistance or a Hoyer lift for transfers, and moderate to maximum assistance for ambulation. He could use utensils to feed himself some foods, but continued on G-tube feedings. He could assist with hygiene. He could nod yes/no. Per a comprehensive rehabilitation evaluation dated 11/3/04, the patient received further Botox injections secondary to increasing spasticity. His mobility was unchanged. Strength was 2- to 3+ in lower extremities with 1/5 in the left ankle and 3- to 5 in the right with bilateral ankle-foot orthotics. A request has been made for acute rehabilitation services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients condition.The patient sustained a severe brain injury in March 2003 and has made gradual progress since the date of injury. Though he experienced a major setback in April 2004 with an Achilles tendon release, he again progressed with subacute rehabilitation. It appears the patient has made significant progress since his discharge on 8/16/04. Based upon the records provided, the patient has emerged from a coma and has made good progress with therapy. While further rehabilitation is indicated, the patient does not require care in an acute inpatient setting. Therefore, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be upheld.