Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Spinal injury.
Treatment:  Inpatient Admission to Acute Rehabilitation Facility.

The insurer denied the Inpatient Admission to Acute Rehabilitation Facility.  The denial is overturned. 

The patient is a male with history of gunshot wound leading to T11 (eleventh thoracic spine vertebra) ASIA (American Spinal Injury Association) C (incomplete spinal injury impairment; motor function is preserved below the neurologic level, and most key muscles below the neurologic level have a muscle grade of less than 3) traumatic Spinal Cord Injury with paraplegia with predominantly L1/L2 (first lumbar spine vertebra/second lumbar spine vertebra) injury and associated fracture of L1 (first lumbar spine) pedicle, intramural aortic hematoma. Subsequently, he had L1/L2 (first lumbar spine vertebra/second lumbar spine vertebra) laminectomy with repair of dura, etc.

The patient was admitted to acute inpatient rehabilitation and developed PE (pulmonary embolism) that led to transfer back to acute admission. The patient was transferred back to Acute Inpatient Rehabilitation Facility (IRF).

Prior to admission, the patient was independent with ADLs (activities of daily living), living alone in a second floor apartment with plan to be discharged home or to live with his sister.

On admission, the patient was dependent on most ADLs (activities of daily living). As of the first date in question, he was supervision or contact guard for sitting, transferring to chair, requiring moderate assistance with lower extremity dressings and most other activities.

The request for extension was towards improving ADLs (activities of daily living), with independence with wheelchair to bed transfer, functional transfer training, endurance training, etc. He continued to complain of pain. He was deemed to be ready for discharge.

The patient was independent with rolling WC (wheelchair) and transfer, eating, hygiene, oral hygiene, dressing and requiring supervision with shower. Plan was to discharge home with home aid assistance.

Yes, the Acute Rehabilitation Facility was medically necessary.

The patient met all the criteria for acute rehabilitation care INTERQUAL Criteria for Acute Rehabilitation in a patient with General Debility and weakness. His status was T11 (eleventh thoracic spine vertebra) ASIA (American Spinal Injury Association) C (incomplete spinal injury impairment; motor function is preserved below the neurologic level, and most key muscles below the neurologic level have a muscle grade of less than 3) Traumatic Spinal Cord Injury with paraplegia. On admission, he was dependent on most ADLs (activities of daily living). He was supervision or contact guard for sitting, transferring to chair, requiring moderate assistance with lower extremity dressings and most other activities.

Based on meeting the above requirements, the patient has met the criteria for more intensive acute inpatient rehabilitation to enable him return home and be independent with some level of ADLs (activities of daily living).

The patient required moderate assistance with most ADLs (activities of daily living) and would be better served at the level of rehabilitation of acute IRF (inpatient rehabilitation facility) than any other lower level of care.