Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral Infarction, Hemiplegia, and Hemiparesis

Treatment: continued sub-acute rehabilitation stay

The insurer denied coverage for continued sub-acute rehabilitation stay

The denial is overturned.

This is a male patient who presented with a left facial droop and slurred speech, and left-sided weakness, and was found to have a right M2 superior division occlusion status post tissue plasminogen activator (tPA), complicated by hemorrhagic conversion, right parietal temporal region hematoma with significant mass-effect and midline shift to the right, status post decompressive hemicraniectomy and emergency evacuation, status post successful intubation, extubation, AED course of Keppra and he was cleared to start anticoagulation. The patient also tested positive for Covid-19 infection.  Physical therapy notes stated that the patient was participating in skilled physical therapy and remained highly motivated at each session. The patient presented with left inattention, internally and externally distracted, and required ongoing cues for attention to task. The patient had improved ambulation strength.  The diagnoses at that time included cerebral infarction due to thrombosis of right middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified abnormalities of gait and mobility, and unspecified lack of coordination.
Based on the review of the medical record, this patient suffered from left hemiparesis, abnormalities of gait and mobility, and deficits in coordination status post a significant stroke. The patient required a craniectomy due to cerebral edema and continues to wear a helmet for safety. At baseline, the patient was Max A for ambulation at parallel bars, and Max A for standing, and sitting. The patient was Mod A for stand-pivot transfers, transfers, and Max A for bed mobility. Ultimately, the patient was Mod A with hemiwalker for ambulation, and remained Max A for dynamic standing, improved in sitting to Min-Mod A, remained Min-Mod A for stand-pivot transfers, and no progress noted with transfers and bed mobility as per the physical therapy (PT) progress note. 
Although the patient was functionally approaching plateau and for discharge to a lower level of care, the patient experienced an adverse event. The patient spiked a low grade fever and had a fall for which he was evaluated in the Emergency Department (ED); he was tested positive for Covid-19 infection. The patient's disposition plan had to be modified, including need for doxycycline for anti-inflammatory properties/treatment of bronchitis and family training. Discharging the patient would not have been standard of care and would have been inappropriate for a patient with this clinical presentation and history. It was imperative to monitor the patient for 3-4 days and provide family training and counseling regarding this patient's overall care. The patient's family needed to be counseled and trained regarding this patient's COVID-19 infection in addition to his discharge needs due to his recent stroke.  Thus, the continued sub-acute rehabilitation stay is considered medically necessary as the patient had skilled needs to facilitate a safe discharge home.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.
Based on the above, the medical necessity for continued sub-acute rehabilitation stay is substantiated.  The insurer's denial should be overturned.