Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left wrist and ankle fractures.
Treatment: Acute rehabilitation facility stay.	
The insurer denied coverage for an acute rehabilitation facility stay.
 The denial is upheld.

This patient presented to the hospital via emergency medical services due to a motorcycle accident. He suffered left wrist and ankle fractures, as well as widespread friction burns (abdomen, legs). He underwent surgical open reduction and internal fixation (ORIF) and is non-weight bearing for the left wrist and left leg. He was at the time of pre-admission screen, using a platform walker, and was a moderate assist for transfers and self-care. Hemodynamics appeared stable. Pain control was ongoing.

The healthcare plan acted reasonably, as the denial for the acute rehabilitation facility stay was appropriate, in this case.      

The acute rehabilitation facility stay is not considered medically necessary for this patient.

The records do not indicate that there are significant or complex medical/nursing issues that could not be addressed at a lesser level of care. Ongoing medication management, skin care, labs, vital signs monitoring, and daily therapy can be provided at a lesser level of care. As such, the stay in question is not determined to be medically necessary.

"In the United States, we are blessed with many options for post-acute care: inpatient rehabilitation facilities, long-term acute care hospitals, skilled nursing facilities, home health agencies, and outpatient rehabilitation. However, choosing the appropriate level of care can be a daunting task. It requires interdisciplinary input and involvement of all stakeholders. The decision should be informed by outcomes data specific to the patient's diagnosis, impairments, and psychosocial supports." (Mayer, R. S. et al. 2020).

"Individuals with health conditions or injuries may require rehabilitation across the course of their lifespan. The timing and type of intervention that a rehabilitation provider selects depend greatly on several factors. These include the etiology and severity of the person's health condition, the prognosis, the way in which the person's condition affects the person's ability to function in the environment, as well as the individual's identified personal goals.

Rehabilitation services may be delivered in any setting (including in hospitals and in communities), depending on the individuals' needs and situation. In hospitals, acute rehabilitation is particularly important in facilitating recovery, maximizing the effect of emergency and surgical services, preventing complications, and ensuring that the optimal functional outcome is achieved. Rehabilitation in the community similarly aims to optimize functioning in those who are not in the hospital system, to identify needs, and to provide services in a person's typical environment. Community rehabilitation services frequently are accessed by those with chronic health conditions or sensory impairment, as well as by children with developmental conditions." (Mills, T. et al
2017).                                                         

The insurer's denial of coverage for the acute rehabilitation facility is upheld. Medical Necessity is not substantiated.