Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cerebral palsy, chronic mild cognitive impairment and Turner syndrome.  
Treatment: Continued subacute rehabilitation 
The insurer denied the Continued subacute rehabilitation. 
The denial is overturned. 

The patient is reported to self-identify as a male. He has a history of cerebral palsy, chronic mild cognitive impairment and Turner syndrome.  There is a complex past medical history, the chronology of which is incompletely documented in the available records.  This history includes cerebrovascular arteriovenous malformation (s/p [status post] partial embolization), left thalamic intraparenchymal hemorrhage (no date provided), epidural hematoma (s/p craniotomy, unspecified date), acquired/obstructive hydrocephalus (not further specified), infected ventriculoperitoneal shunt (not further specified), gastrostomy tube placement, seizure disorder, aseptic meningitis, asthma, neurogenic bladder and deep venous thrombosis.  The patient's baseline functional status is unclear from the available records.

Yes, the Continued subacute rehabilitation is medically necessary.

The records indicate that the patient has had a series of acute health compromises.  He was in an acute hospital.  He was doing rehabilitation for 2+ months, but then became ill with COVID-19.  He resumed subacute inpatient rehabilitation but functional progress has been slow.

Notably, there is a history of multiple cerebral insults, now chronic in nature, with significant residual weakness affecting all four limbs.  There is less than antigravity strength in the right lower limb and only fair plus strength in the left lower limb.  The upper body is not strong enough to fully compensate for the lower body weakness.  This level of generalized weakness precludes safe, functional community ambulation and explains for the most part why there has been limited progress made in terms of ambulation with assistive devices.  Transfers and ambulation would be expected to require significant levels of assistance indefinitely.

There is no documented progress with compensatory but practical measures such as family training with transfers or activities of daily living, or training with a power mobility device for independent mobility.  The rehabilitation course as documented, overall, has not been consistent with a realistic likelihood of successful community reintegration at any point in the foreseeable future, when the goals (as reported in the records) are indicated to be full independence with self-care and mobility before community reintegration.  Accordingly, the available records indicate that the facility staff have anticipated that the patient will remain at the facility as a long-term care resident.

There are no documented concomitant skilled nursing or medical needs that support the need for ongoing inpatient hospital level care.  There have, nonetheless, been indications of some functional progress with transfers and ambulation over the last few weeks.  While it is anticipated that the patient will require long-term care facility residence for the long-term, additional rehabilitation with skilled multidisciplinary rehabilitation therapy services (including occupational therapy and physical therapy) is appropriate and necessary to maximize function to decrease burden of care before transitioning to a long-term care level of care.  One practical, meaningful and potentially realistic goal, for instance, would be improving transfers to 1 person assist, so that aide staff in a long-term care setting can provide 1 person physical assist transfers instead of using mechanical patient transfer devices (e.g., a Hoyer lift).  The services in question should be approved, with reassessment periodically to determine when the patient has plateaued functionally, and transition to custodial care is warranted.