Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status Post Brain Injury. 
Treatment: Continued Skilled Nursing Facility (subacute rehabilitation level 1). 

The insurer denied: Continued Skilled Nursing Facility (subacute rehabilitation level 1). 
The denial is upheld. 

The patient is an adult male. He was fully independent at baseline, living with family, and working in the restaurant industry. The patient was a pedestrian struck by a car while crossing the street 8 months ago. There was a witnessed seizure at the scene, as well extensive posturing. He had a Glasgow coma scale score of 4 on arrival to an acute hospital/trauma center. He was found to have sustained injuries that included multifocal cerebral contusions and hemorrhages, with concern for severe hemorrhagic diffuse axonal injury. He received a tracheostomy and gastrostomy feeding tube. He is reported to have been in a coma for several weeks, then he showed evidence of minimal consciousness.  The patient was transferred to an acute inpatient rehabilitation hospital for acute brain injury rehabilitation. His early acute inpatient rehabilitation course was notable for restlessness, mood lability, and periods of agitation. Six months ago, the patient's tracheostomy was decannulated. As of a week ago, occupational therapy noted that the patient continued to have significant impairments with sustained attention, memory, and insight into deficits. He was noted to have a nonfunctional, contracted left upper limb. He had normal tone and motor control of his right, dominant upper extremity. He was noted to require moderate 1:1 (one to one) assist for feeding, max assist for bathing, and max to total assist for dressing. It was reported that the main emphasis of care was aggressive passive range of motion for the left upper extremity. Physical therapy noted that he was dependent with bed mobility and transfers. He was being transferred by mechanical lift. He was tolerating 12 minutes on the tilt table at 40 degrees. He was wearing a static progressive left knee ankle foot orthosis. He was spending time sitting in a tilt-in-space wheelchair. Speech therapy noted that he had severe cognitive deficits. Progress was noted to be slow. He was on a soft and cut up solids and thin liquids oral diet with 1:1 supervision. 

The team conference noted that the patient was ready to transition to a facility versus going home. The hospital's case manager noted that a bed at a skilled nursing facility level of care had been offered at a different facility, but the patient's family member (and health care proxy) declined the offer feeling that the facility was "subpar" and "not safe" for the patient. It was felt by the treating team that the patient needed to remain at the hospital at a subacute level of care until a bed at an appropriate skilled nursing facility could be secured or everything could be set up for the patient to return to the community. 

The health plan denied coverage of the service under review (continued subacute inpatient rehabilitation), indicating that the service is not medically necessary as his care can be provided at a lower level of care. 

The Continued Skilled Nursing Facility (subacute rehabilitation level 1) is not medically necessary.

The patient has undergone extensive, intensive, inpatient rehabilitation. He has remained severely impaired cognitively and physically. He has remained essentially at a max to total assist level for his basic self-care and mobility. While the patient continues to have rehabilitation needs, he does not require intensive therapies at a subacute inpatient rehabilitation level of care. He can receive the passive range of motion, splint applications, custodial level assist for his basic self-care and transfers/mobility/repositioning, and intermittent skilled therapy visits for adjustments to his program that he needs at a lower level of care. He has a guarded prognosis overall given the severity of his traumatic brain injury and his course to date, including his very limited recovery. He has been ready for transition from his current facility to a lower level of care. The requested continuation of coverage of a subacute inpatient rehabilitation level of care after the last covered date is not medically necessary.