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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage long-term acute care services. Long-term acute care hospital (LTACH) level care is intended for patients requiring care that is more medically complex than can be handled at lower levels of care such as inpatient rehabilitation facilities or skilled nursing facilities. Examples of treatments consistent with LTACH level of care include chest tubes, extensive wound care, stable cardiac drips, multiple intravenous antibiotics, hemodialysis/peritoneal dialysis, prolonged intravenous therapy, total parenteral nutrition, tracheostomy care/extensive pulmonary services, ventilator weaning, and frequent imaging/laboratory testing. Generally, LTACH level of care patients require a combination of treatments, along with documented prior treatment failure at lower levels of care and/or a reasonable expectation of treatment failure at lower levels of care. A stay of greater than 25 days should generally be expected. In this case, the patient had a prior history of traumatic brain injury, then developed anoxic brain injury related to a cardiac arrest with a prolonged resuscitation effort. As of the previous month, he had been at the long-term acute care hospital for almost two months. He was stable and remained nonresponsive in a persistent vegetative state. There were intermittent episodes of mild pyrexia, with negative infectious work-ups, which may have been due to dysautonomia associated with brain injury. There was some hyponatremia, which was stable, and also possibly associated with brain injury. The patient had a tracheostomy and was not going to be decannulated. His cardiac status was stable, with paroxysmal atrial fibrillation being medically managed. He was stable nutritionally on enteral tube feeds, and had a condom catheter. He had leg swelling due to a chronic deep venous thrombosis, and a chronic sacral wound that was not documented to require complex nursing wound care. The records indicate the patient remained clinically stable in a persistent vegetative state due to anoxic brain injury with encephalomalacia, with dysautonomia manifesting as central fever. There were no ongoing intensive medical or nursing needs consistent with the LTACH level of care. There were no more complex medical treatments, or need for frequent testing beyond maintenance monitoring. Thus, the services at issue could be provided at a lower level of care than at a LTACH facility. Therefore, long-term acute care services were not and are not medically necessary for the treatment of this patient.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.