Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cerebral Vascular Accident (CVA)
Treatment: Continued stay in subacute rehabilitation.
The insurer denied the continued stay in subacute rehabilitation.
The health plan's determination is upheld.

The patient is a male with nontraumatic intracerebral hemorrhage, hemorrhagic stroke, mild right sided weakness, right femur fracture status post open reduction internal fixation (ORIF), venous insufficiency, deficiency of B group vitamins, chronic pain due to trauma, rheumatoid arthritis, depression, hypertension, idiopathic hypoparathyroidism, and drug induced constipation. His vital signs were stable. He was alert and verbally responsive. He was incontinent of bowel and bladder. He was day 1 post admission with the diagnoses of nontraumatic intracerebral hemorrhage and right femur fracture status post ORIF. He required limited assistance with activities of daily living (ADL's) and was continent of bowel. He complained of right hip pain due to the right femur fracture. Medications included oral Tramadol, Capsaicin topically and Aspercreme topically for pain. His pain level was mild to moderate. He was prescribed Ibuprofen. His cognition, expressive communication, comprehension, and oral motor skills were normal. His swallowing was normal and speech therapy was not indicated.
Upon examination, he was awake, alert, and oriented times 3 with slurred speech. There was mild residual right sided weakness with significant ataxia. His finger to nose was worse on the right. He was one person assist for walking. He had significantly improved. There was no joint swelling, his muscle tone was normal and his cranial nerves were normal. There was mild right sided weakness. His vital signs were stable. He had an intracranial hemorrhage and hemorrhagic stroke with mild residual right sided weakness. The most likely etiology was hypertensive urgency. He was allowed out on pass with an escort and an assistive device. The following day, he presented to the hospital with right sided weakness after a fall at home with loss of consciousness. 
He was transferred to a subacute rehabilitation facility. He had right sided weakness, tingling, and numbness. Upon examination, his vital signs were stable. His neck was supple. His extremity musculature was symmetrical. There was decreased active range of motion of the right upper extremity. There was dysarthria, dysmetria with finger to nose testing, right hemiparesis, and ataxia. 


The requested health service/treatment of continued stay in subacute rehabilitation is not medically necessary for this patient. He had right sided weakness, tingling, and numbness. Upon examination, his vital signs were stable. His neck was supple. His extremity musculature was symmetrical. There was decreased active range of motion of the right upper extremity. There was dysarthria, dysmetria with finger to nose testing, right hemiparesis, and ataxia. The occupational therapy note stated that he was independent with oral hygiene, independent with eating, required supervision or touch assistance with toileting hygiene, toileting transfers, showering/bathing, and donning/doffing footwear. He required setup or clean up assistance with upper and lower body dressing. The physical therapy note stated that he was independent, set-up, or cleanup assistance with bed mobility. He was setup or clean-up assistance with sit to stand and chair/bed to chair transfers. He was supervision or touch assistance for toilet transfers. He required supervision or touch assistance for walking 50 feet. He could ambulate 90 feet with a two wheeled walker. The patient could participate in a home exercise program, outpatient physical therapy and occupational therapy, or treatment in an alternative facility for strengthening, functional exercises, and range of motion exercises. 

The health plan's determination of medical necessity is upheld in whole.