Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) three sessions per week of physical therapy and (2) three sessions per week of speech therapy. Functional impairments due to acquired brain insults such as stroke can be severe to profound. Belagaje notes that rehabilitation is an important aspect of the continuum of care in strokes, and that successful rehabilitation involves understanding the natural history of stroke recovery and a multidisciplinary approach to identify and treat common poststroke sequelae. Kubis notes that patients may improve spontaneously within the first three months and then more slowly in the coming year. Rehabilitation services are rendered first in the inpatient setting, followed by rehabilitation in the community setting if still indicated, based on impairments and the potential for achieving practical, functional goals. Rehabilitation efforts are indicated at a level of intensity commensurate with deficits until care can be safely and effectively transitioned to a less intensive level of care. In this case, the patient sustained a severe hemorrhagic stroke in the setting of malignant hypertension requiring surgical hematoma evacuation.  The patients course was complicated by several medical issues including seizure disorder, infections, prolonged mechanical ventilation dependence, and acute kidney injury resulting in renal failure requiring ongoing hemodialysis.  The records note a gradual functional recovery, and the patient is noted as making slow but clear gains in mobility at a wheelchair level and in transfers using a sliding board.  While it is likely that this patient will require significant assistance from others indefinitely, optimizing his independence and decreasing his burden of care are appropriate and necessary at this time, and ongoing skilled physical therapy is medically indicated to maximize his functional mobility. Therefore, (1) three sessions per week of physical therapy are medically necessary for the treatment of this patient. While the records note ongoing cognitive and language deficits, the patient has been transitioned to a regular consistency oral diet, which he has been tolerating. Additional formal speech therapy would not be expected to improve the patients outcomes, given the lack of proven efficacy of therapeutic interventions for these types of impairments at this stage of the patients convalescence. Therefore, (2) three sessions per week of speech therapy are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.