Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Skilled Nursing Facility. 

The insurer denied: Skilled Nursing Facility. The denial is overturned in whole. 

The patient is a male with B cell acute lymphocytic leukemia (ALL) (in remission for 3 years), resolved drug induced liver cirrhosis, developmental delay and intractable epilepsy who was initially admitted for right craniotomy for resection of epileptic foci. Post-surgery he was admitted to the Pediatric Intensive Care Unit (PICU) and was noted to have left sided weakness and some aphasia as expected per neurosurgery team. Two days later the patient was noted to be difficult to arouse and had worsening left sided weakness. He was taken for magnetic resonance imaging (MRI) for concern for possible infarct. His MRI indeed revealed an infarct in the right parietal region. 

He was admitted to inpatient rehabilitation for comprehensive rehabilitation, continued medical management, caregiver education and discharge planning. He was noted to have resultant left hemiparesis, motor deficits, impaired expressive and problem solving skills, followed by brain injury team and received intensive therapies with improvements. He was placed on an anti-epileptic regimen of clobazam, lacosamide, levetiracetam and phenytoin. Phenytoin was weaned and during Phenytoin wean the patient had multiple breakthrough seizures and required as needed (PRN) midazolam. With intensive therapies he was able to walk short distances (200 feet) with rolling walker, splints and contact guard assistance. He was able to walk very short distances (20 feet) without any assistive device and maintain static standing with equal weight through both lower extremities. The patient still was unable to perform the stairs he needed to complete in order to be discharged. By discharge he was able to walk 200 feet with a frontal walker but still had hyperextension of left knee during weight bearing despite lift and splint. Patient made progress since admission with intensive therapies and was cleared for discharge home. 

The subject under review is the medical necessity for the continued stay in the skilled nursing facility. 

The requested health service/treatment of Continued Stay in a Skilled Nursing Facility is medically necessary for this patient. 

This patient, with intractable epilepsy, was s/p craniotomy for resection of epileptic foci. 
Given his medical history and deficits after post op stroke, this patient would meet New York State (NYS) criteria for Medically Fragile Child (MFC). The definition of a "medically fragile child" is an individual who is under 21 years of age and has a chronic debilitating condition or conditions, who may or may not be hospitalized or institutionalized and meets one or more of the following criteria: 1) is technologically dependent for live or health sustaining functions, 2) requires a complex medication regimen or medical interventions to maintain or to improve their health status, 3) is in need of ongoing assessment or intervention to prevent serious deterioration of their health status or medical complications that place their life, health or development at risk. Given his medical history and deficits after post-op stroke, this patient would meet NYS criteria for Medically Fragile Child (MFC). With this designation, the plan supports accommodating unusual stabilization and prolonged discharge plans for MFC as appropriate. Provisions in the plan wording also support the need to await an appropriate home or home-like environment than discharge to a housing shelter or other inappropriate setting for a MFC. 

For these reasons and per the NYS Department of Health provisions for MFC, continued stay in a skilled nursing facility was medically necessary for this patient.