Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Other - Guillain Barre Syndrome
Treatment: Continued sub acute rehabilitation admission
The health plan denied: Continued sub acute rehabilitation admission
The determination is: Upheld

The patient is a male with a medical history notable for Guillain Barre Syndrome (GBS). The patient was admitted to the subacute rehabilitation facility following an inpatient hospital admission where he was diagnosed with GBS. He was treated with intravenous immunoglobulin (IVIG) and steroids and showed some improvement before moving facilities for ongoing rehabilitation. Physician notes were provided for review. He was seen by a psychiatrist for management of post-traumatic stress disorder (PTSD), depression, and nightmares. He was seen by dermatology, neurology, and podiatry as well. He has avascular necrosis of the hips and will need a bilateral hip replacement at some point in the future. There was no documentation regarding difficulties with discharge planning.

Physical and Occupational Therapy notes were provided for review. As of the start of the period in question, the patient had 3/5 strength in the bilateral lower extremities and 3+/5 in the trunk. His static standing ability was rated as Good-/Fair+, as he was able to maintain standing balances without support against minimum resistance. He was able to ambulate on level surfaces up to 175 feet. He was able to perform transfers with supervision for safety awareness. Subsequent notes indicate that the patient continued to improve throughout the period in question with continued therapy as he moved closer to his baseline. Occupational therapy notes indicate that the patient was mostly able to perform activities of daily living (ADL) at the time of the start of the date period in question.

A letter of support for this appeal was provided by the inpatient rehabilitation facility. The letter states that the patient is not yet safe for discharge back to the community. They state that "the family feels that continued care will benefit the patient by decreasing the level of pain, improving gait performance, and improving functional mobility to the highest level."

At issue is the medical necessity of the continued inpatient rehabilitation stay.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of continued inpatient rehabilitation stay is not medically necessary for this patient.

The patient was diagnosed with Guillen Barre Syndrome and was admitted to subacute rehabilitation for further therapy. He showed steady progress and improvement with time and ongoing therapy. At the time of the requested extension of inpatient services, the patient had improved significantly and did not require skilled services. There were no letters of medical necessity provided by his physician or explanation for why his therapy services required an inpatient rehabilitation instead of an alternate level of care. It is not clearly established that there is medical necessity for an ongoing inpatient stay. The letter that was provided from the facility mentions that the patient's family requested an ongoing stay to allow him to reach his maximal therapy potential, but this process could take an extended period of time and is not, in itself, an indication for an inpatient rehabilitation stay.