Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer

The patient is a 28-year-old male who sustained a fall of approximately 30 feet while rock climbing on 1/29/17.  Initial Glasgow Coma scale score was 6 in the emergency room.  There was decorticate posturing.  Imaging showed an occipital skull fracture and multiple intracranial bleeds, including intraparenchymal and intraventricular bleeds.  There was a traumatic right carotid dissection/aneurysm.  He also sustained right wrist fractures.  He underwent a craniotomy/external ventricular drain placement on 1/29/17, right craniectomy on 1/30/17, bone flap removal on 1/31/17, right distal radial fracture open reduction on 2/2/17, tracheostomy on 2/3/17 and gastrostomy on 2/28/17. On 3/13/17, he was transferred to another hospital for further medical stabilization. On 4/8/17, he was transferred to a long term acute care hospital for further care.  On 5/4/17, he underwent cranioplasty.  His neurological status waxed and waned.  He was noted to have progressive hydrocephalus.  On 6/17/17, he was readmitted to the acute hospital and underwent external ventricular drain placement.  He was deemed to not be a candidate for ventriculoperitoneal shunt placement at the time.  On 6/30/17, he was transferred to a skilled nursing facility for further care.  He was following some commands and had some vocalizations, but was not speaking.  On 9/22/17, he underwent ear tube placements in anticipation of hyperbaric therapy. On 10/11/17, he was admitted to acute inpatient rehabilitation.  He had a seizure.  Imaging showed marked hydrocephalus, stable versus prior imaging on 8/31/17, as well as encephalomalacia.  He was transferred to the acute hospital on 10/25/17 for elective ventriculoperitoneal shunt placement.  He underwent surgery on 10/25/17, without complications, and stayed overnight for observation.  He returned to acute inpatient rehabilitation on 10/26/17. A repeat head computed tomography on 10/27/17 showed a large right subdural hematoma so he was readmitted to the hospital for further care.  His shunt was adjusted.  He returned to acute inpatient rehabilitation again on 10/30/17. On 10/30/17, the providers admission examination noted that he was tracking.  He was moving his left fingers slightly on request.  He was withdrawing in all four limbs to painful stimuli.  He was being weaned off of amantadine due to potential lowering of seizure threshold.  He was on anti-seizure medication.  He was on modafinil, dantrolene, gabapentin, a beta blocker, a proton pump inhibitor, melatonin, iron, cholecalciferol and bowel medications.  He was taking nothing by mouth. He was on bolus tube feeds by gastrostomy.  He was on timed voids. He underwent inpatient rehabilitation.  As of the 12/5/17 team conference, he was dependent for self-care, mobility, comprehension, expression, cognitive tasks, and social interaction.  He was nonverbal.  He was visually tracking at 80 to 100% of the time.  He was consistently moving his left hand and fingers on command. His tolerance for use of a standing frame was limited by ankle inversion tone and a foot wound.  Family training was in progress. On 12/6/17, the team conference findings were presented to the patients family. It was noted that the patient was making incremental progress and there were no goals that would support the need for ongoing acute inpatient rehabilitation level of care. The provider noted that additional inpatient rehabilitation was to be reviewed from week to week. The patient has requested reimbursement and prospective authorization and coverage for inpatient rehabilitation level 1 facility services from 12/19/17 forward. Per the Health Insurer, the services at issue were not and are not medically necessary for the treatment of this patients medical condition. Therefore, the Health Insurer has denied coverage for the services at issue.  This denial is the subject of this appeal and determination. The documentation provided does not support the medical necessity of the services at issue in this patients case. Functional impairments due to traumatically acquired brain insults can improve with time (natural recovery processes). These impairments are also amenable to rehabilitation interventions. However, deficits can remain severe, particularly in the setting of traumatic injuries. A protracted period of functional dependency following intracerebral hemorrhage, in particular, can be high.	 In the present case, the patient sustained a severe traumatic brain injury due to a fall from a height of approximately 30 feet while rock climbing. By 12/6/17, he had made minimal functional progress despite extensive medical, surgical and rehabilitative care. The patient continued to have profound functional deficits in the cognitive and physical domains.  Despite more than one month of this latest round of inpatient rehabilitation, he remained essentially dependent for all aspects of his care.  He continues to have ongoing care needs, but these were largely custodial in nature.  Intermittent therapy services could have been provided at a less intensive setting of care than acute inpatient rehabilitation.  His course and outcomes would not have been expected to be marginally improved with a higher intensity of rehabilitative services as of December 2017. His prognosis for meaningful functional recovery would have remained very guarded on account of the severity of his underlying injuries. He would have remained at high risk for health related complications regardless of care setting.  Notably, his treating providers have  not supported the medical necessity of ongoing acute inpatient rehabilitation as of the 12/5/17 team conference. Their recommendation was an appropriate conclusion based on the clinical data at the time.  Higher acuity rehabilitation services could be reconsidered if additional, reliable movements and abilities warranting these rehabilitation services emerged in the future.  As such, inpatient rehabilitation level 1 facility services from 12/19/17 forward were not and are not medically necessary for treatment of this patients medical