Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Intra-cranial hemorrhage.
Treatment:  Admission to acute rehabilitation. 
The insurer denied the Admission to acute rehabilitation.  The denial is overturned.

The Admission to acute rehabilitation is medically necessary.

The patient is a female with history of large spontaneous intra-cranial hemorrhage (subdural hematoma) secondary to a ruptured AVM (arteriovenous malformation) and s/p (status post) clot evacuation through decompressive hemicraniectomy/resection.  Acute inpatient hospital admission was complicated by need for tracheostomy with difficulty in decannulation, dysphagia requiring PEG (percutaneous endoscopic gastrostomy)-tube feeding, hypokalemia, acute-on-chronic renal failure that resolved after hemodialysis without further need for hemodialysis, several abdominal surgeries for multiple abscesses, tracheobronchitis, and periodic tachycardia. 

The patient's relevant past medical history includes Hypertension, Diabetes Mellitus, and hypothyroidism.

Prior to onset of intra-cranial hemorrhage, the patient was independent and living with spouse. 

It was documented that the patient was able to follow one-step commands, oriented to person, and willing/able to participate in PT/OT/SLP (physical therapy/occupational therapy/speech language pathology).  She requires management of her hypokalemia, hypercalcemia, secretions from her tracheostomy, management of her PEG-tube and feeding, sporadic tachycardia, stage IV sacral decubitus ulcer and fluctuation in her blood sugar while requiring moderate to maximum assistant with most activities with dependence for toileting and limited by spasticity of her limbs.

The patient met all the criteria for acute rehabilitation care INTERQUAL Criteria 2019 for Acute Rehabilitation in a patient with CNS/TBI (central nervous system/traumatic brain injury) as she requires cognitive rehabilitation, medication with cerebral stimulants, maximizing neuromuscular stimulation/function in view of SLP, OT and PT rehabilitation, all of which will not be available in a lower level of care.  It was documented that she was able to follow one-step commands, oriented to person, and willing/able to participate in PT/OT/SLP.  She requires management of her hypokalemia, hypercalcemia, secretions from her tracheostomy, management of her PEG-tube and feeding, sporadic tachycardia, stage IV sacral decubitus ulcer and fluctuation in her blood sugar while requiring moderate to maximum assistant with most activities with dependence for toileting and limited by spasticity of her limbs.

Based on meeting the requirements for acute inpatient rehabilitation, it is medically necessary for the patient to be admitted to the acute inpatient rehabilitation, as she requires cognitive rehabilitation, medication with cerebral stimulants, maximizing neuromuscular stimulation/function in view of SLP, OT and PT rehabilitation, while also managing her current acute medical issues, all of which will not be available in a lower level of care.

Based on the above rationale, the patient with history of non-traumatic brain injury is more than likely to benefit from an acute TBI rehabilitation that is more than likely to help her towards greater recovery as compared with a lower level of care.

The recommended length of approval is two weeks to show participation with re-evaluation at that time for continued medical necessity towards a total of four weeks.