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

Nature of Statutory Criteria/Case Summary: An enrollee has requested acute rehabilitation and skilled nursing facility (SNF) services for treatment of the enrollees non-traumatic cerebral intraparenchymal hemorrhage.  Findings: The physician reviewer found that the documentation does not reveal that this patient requires SNF services. The evidence for both acute and post-acute rehabilitation stroke care suggests that organized care for post-stroke patients is indicated to achieve optimal outcomes, and the outcomes measured are substantial. In the medical literature, Cifu and Stewart demonstrated that in comparing the effectiveness of multidisciplinary inpatient physical rehabilitation programs with standard medical care, rehabilitation services improved short-term survival, functional ability, and most independent discharge location. However, the research did not reveal long-term benefits. The authors noted that, the lack of long-term benefits of short-term rehabilitation may suggest that therapy should be extended to home or subacute care settings, rather than being discontinued at discharge. Further, the heterogeneity of the literature with regard to stroke patient samples, structural design, and outcome measures, reveal that it is difficult to identify a best practice that applies to all patients with stroke. The evidence does not indicate the specific nature of the intervention, provide explanation of the nature of the team approach, or outline which factor has the greatest impact on patient outcome. There is a lack of evidence that the patient currently requires such SNF services as intravenous or enteral feeding, tracheotomy aspiration, suprapubic catheter care, treatment of a stage 3 or greater decubitus ulcer, institution of a bowel/bladder training program, colostomy care, or other skilled nursing need. The patient is not expected to make measurable gains within a reasonable and predictable period of time given her physical therapy notes which reveal a recent slowing in progress in therapy. The patient does not require skilled therapy on a daily basis to prevent deterioration with mobility and/or ADLs. The patient does not require skilled therapy to establish a safe and effective maintenance program as the patient and caregivers have been educated in the patients care. Without clear skilled nursing needs the patient does not require SNF services to establish a safe and effective maintenance program. Moreover, the records do not reveal that the patient has continued complex medical conditions that require close provider involvement in the patients care from a rehabilitation provider with specialized training and experience in rehabilitation. All told, this patients records do not support the medical necessity of acute rehabilitation and SNF services.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.