Appeal type: Medical necessity
Decision: Upheld

Diagnosis: S/P (status post) Stroke.
Treatment: Continued acute rehabilitation.

The insurer denied the Continued acute rehabilitation.  The denial is overturned. 

The patient is a male. The patient was mowing his lawn when he became dizzy and developed weakness in his left arm and left leg. He presented to a local emergency room, where he received tissue plasminogen activator (tPA) therapy for an acute stroke. He was then transferred to a tertiary acute hospital for further care.

The patient was hemodynamically stable on arrival. On physical examination, he had normal range of motion and strength in the limbs. There was left upper extremity dysmetria. Sensation was intact. There were no cognitive deficits. Electrocardiogram was normal. CT (computed tomography) of the head was negative for acute intracranial pathology, including hemorrhagic transformation post-tPA (tissue plasminogen activator). There was 50% stenosis at the origin of the right vertebral artery due to calcific atherosclerosis and occlusion of the left posterior inferior cerebellar artery. MRI (magnetic resonance image) revealed an acute ischemic infarct in the left posterior inferior cerebellar artery territory, to include the cerebellum and medulla. He was monitored on cardiac telemetry.

A loop recorder was implanted for further investigation of a suspected cardioembolic source. Hemoglobin A1c (glycated hemoglobin) was 6.3. There was hematuria. The patient was medically optimized. An indwelling urinary catheter was placed due to retention and he was started on terazosin. His premorbid history was noted to be pertinent for hyperlipidemia, hypertension and diabetes vs borderline diabetes (on metformin once a day at home prior to the stroke). Prior to the stroke, he had been fully independent, living in the community with his spouse, and working as a teacher.

The patient was seen in the acute hospital by physical and occupational therapy. On therapy evaluations, he was noted to have a hoarse voice. He had significant left upper extremity coordination deficits. There was minimal left-sided inattention. He was requiring max assist for lower body self-care.

No, the Continued acute rehabilitation was not medically necessary.

The patient had sustained an acute left posterior inferior cerebellar artery distribution stroke with imaging evidence of cerebellar and medullary involvement, but no clinical indications of significant medullary pathology/Wallenberg syndrome (e.g., cranial nerve palsies, dysphagia, dysarthria, new dysphonia, hemodynamic instability, or sudomotor dysfunction), outside perhaps of his hiccoughs. He did have severe hiccoughs, which are associated with Wallenberg syndrome, but these typically resolve over time spontaneously over several weeks and, in any case, are generally intractable to pharmacotherapy or other medical interventions. Moreover, while the hiccoughs can be uncomfortable and inconvenient, they are not in and of themselves a reason to have to continue an inpatient stay.

By all accounts, the patient's dysphonia and left vocal fold paresis were chronic and pre-existing before the stroke. Both the otolaryngologist and the rehabilitation physician noted that he had had the same voice chronically, well before his stroke, and that it had not changed following his stroke. In any case, there was adequate compensation with the nonparetic vocal fold, with good airway protection. There was, furthermore, no pre-laryngeal/oropharyngeal dysphagia that would have made aspiration a clinical concern. There was no need for any further inpatient level care related to his voice, swallowing or any other otolaryngological issue.

The patient did also develop an apparent urinary retention, but he did well with a voiding trial after his indwelling catheter was removed. Notably, he had a history of occupationally driven urinary retention as a teacher, which likely resulted in a large volume bladder and/or a greater threshold before triggering the micturition urge. This was appropriately addressed with a recommendation for timed voids and increasing the threshold for intermittent catheterizations.

The patient's voiding trial was going well, and he did not require ongoing inpatient level care or monitoring for this issue.

The patient's primary deficits involved his left-sided ataxia and proprioceptive deficits. These deficits, as noted by multiple examiners, were relatively mild. He did not have any significant strength deficits, with his manual muscle testing results ranging generally from 4+/5 to 5/5 since the early aftermath of his stroke. With practice and by using compensatory strategies, including the use of gait implements, a wheelchair, shower bench, and other durable medical equipment to improve his balance and safety, he made significant and practical functional improvements. Functionally, there were no indications that he was not able to perform his self-care and household level mobility tasks in the community with some set up, supervision and occasional contact guard. Further rehabilitation services could have been provided in the community to guide his recovery and convalescence. The rehabilitation of cerebellar strokes is challenging and largely involves compensatory strategies for neurological deficits that will recover on their own timeline. Fortunately, the prognosis for recovery is favorable for partial posterior inferior cerebellar artery distribution infarcts, such as the type of infarct that the patient sustained (particularly in comparison to strokes involving the whole posterior inferior cerebellar artery distribution).