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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for inpatient acute rehabilitative care that includes one-on-one pool therapy.Functional impairments due to traumatically acquired brain insults can improve with time, i.e., natural recovery processes. Researchers state that these impairments are also generally amenable to rehabilitation interventions. According to medical literature, the standard of care for rehabilitation in the setting of acute traumatic brain injury includes efforts to foster neurological recovery, mitigate risk of complications, improve function, advise on appropriate durable medical equipment, train family members/caregivers, and aid in the transition back to the community when feasible. Options for setting of care following the acute hospitalization include long-term acute care hospitals, acute inpatient rehabilitation facilities and skilled nursing facilities. Deficits related to traumatic brain injury can, nonetheless, remain severely functionally impairing, resulting in protracted and profound functional deficits despite natural recovery and rehabilitation interventions. There is a limit to the benefits of ongoing intensive rehabilitation interventions when the impairments are protracted and profound. Notably, researchers found that the evidence base for rehabilitation following severe traumatic brain injury remains limited, particularly with respect to promoting function.With regard to aquatic therapy (e.g., pool-based therapy) specifically, this intervention offers the potential of improving exercise participation for persons with various neurological conditions causing functional impairments. Researchers state that advantages of this environment include reduction of load level on the lower body, reduced fear of falling, optimizing the environment for persons with postural impairments, and potential for offering beneficial environmental stimuli (e.g., the liquid viscosity and floating with perturbations) to promote balance and strength. However, researchers concluded that the efficacy of aquatic therapy in the setting of traumatic brain injury remains very inadequately studied and unproven, particularly with respect to improving basic functional outcomes.In this case, the patient sustained a severe traumatic brain injury that is affecting both hemispheres, but more severely on the left side due to a snowboarding accident. The patient has undergone extensive rehabilitation in the acute inpatient rehabilitation setting. He has made improvement but has persistent severe to profound functional deficits. He remains confused and has limited problem-solving skills. He has severe weakness on the right side. He has difficulty with motor planning and fine motor skills on the left side. At this point, the clinical data provided does not support the necessity of continued acute inpatient rehabilitation. There is no expected benefit of pool-based therapy on the patients outcomes. Therefore, inpatient acute rehabilitative care that includes one-on-one pool therapy is not medically necessary for the treatment of the patients medical condition. 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 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.