Appeal type: Medical necessity
Decision: Overturned

Diagnosis: s/p (status post) Stroke. 
Treatment: Acute Rehabilitation Facility. 

The insurer denied the Acute Rehabilitation Facility. 
The denial is overturned. 

The patient is a male. He had headache and dizziness the day prior to admission, and he was found to have right cerebellar ischemic infarct. He is Right hand dominant. He was previously independent with all tasks. He was now ambulating 20 feet with wheeled walker min assist. He was Min assist with upper body ADL (activities of daily living) and dependent lower body. He had vertigo due to cerebellar infarct, poorly controlled diabetes, lactic acidosis, hypertension, morbid obesity, hyperlipidemia and leukocytes in need of medical evaluation. The plan was also to receive cardiac monitor to assess his arrhythmias. His hemoglobin A1C (glycated hemoglobin) was 8.5, and he is a poorly controlled diabetic. 

The patient had medication adjustments in progress due to lactic acidosis. He was also with BMI (body mass index) over 40 and OSA (obstructive sleep apnea). 

The plan denied coverage of admission to acute rehabilitation facility due to not meeting criteria of 15 hours over 7 days, need for skilled services including RN (nurse), PT (physical therapy), OT (occupational therapy), SLP (speech language pathology) and medical complexity. 

The treating provider is requesting an appeal as the patient had multiple comorbidities including morbid obesity, poorly controlled diabetes, HTN (hypertension) needing monitor placement to assess for arrhythmias and vertigo as medical needs.  Also functionally patient was independent and now min assist with gait and dependent for lower extremity and min assist for upper extremity dress.  Goals were for independent level and home with family.  Patient was motivated and able to participate 3 hours a day of therapy 5 days a week. 

Yes, the Acute Rehabilitation Facility is medically necessary. 

The patient suffered a cerebellar stroke impacting function and balance as well as causing vertigo. He had many comorbidities, including morbid obesity with BMI (body mass index) >40, uncontrolled diabetes mellitus with A1C (glycated hemoglobin) of 8.5 on admission requiring close monitoring by physician and nursing for optimal glycemic control. In addition he was found to have lactic acidosis, thought to possibly be due to medications, thus monitoring in a close setting with medical oversight was needed. The patient also had HTN (hypertension) with fluctuant blood pressures and required a cardiac monitor to assess for any arrhythmias which may have led to the cerebellar infarct.  For these reasons, there was medical necessity to justify acute inpatient rehabilitation as many comorbidities needed daily medical oversight.  He also needed skilled nursing for medical administration, especially for close gylcemic control, and PT/OT (physical therapy/occupational therapy) services to upgrade function to independent level and assist with balance for transition back to community.  He was able to and willing to participate in 3 hours of therapy a day. 

The patient had medical needs that required daily oversight as well as skilled therapy needs and was able to participate in 3 hours of therapy a day.  For these reasons acute inpatient rehabilitation was the appropriate setting for his therapy needs. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 

The plan denied the acute inpatient rehabilitation. The patient met criteria for acute rehabilitation, including need for daily medical oversight due to complex medical needs, PT (physical therapy)/OT (occupational therapy)/nursing/psychology services as well as the ability to participate in intensive therapies of 15 hours in a week.