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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for outpatient day neurologic rehabilitation provided by Centre for Neuro Skills San Francisco. Vos and colleagues report that traumatic brain injury (TBI) is among the most frequent neurological disorders. Marklund and colleagues note extended time frames for the recovery process, which for patients with the most severe TBI may continue over months or even years. The authors quote the World Health Organization (WHO) definition for rehabilitation as, A set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment. The authors further note that brain injury rehabilitation promotes recovery through three main approaches. First, complications in the days to months after brain injury are prevented, detected and managed through frequent, specialized medical follow-up, thus maximizing spontaneous improvement with normalization of network processes as neuroinflammatory and other acute processes resolve. Second, neuroplasticity is promoted by rehabilitation interventions; traditionally, therapies such as physiotherapy, speech and language therapy, neuropsychology, and others, leading to restitution of body function. Third, compensatory rehabilitation interventions maximize independence and quality of life: for example, a wheelchair may enable independent mobility, aids such as kitchen timers may enable safe home living. The authors note that compensatory interventions are particularly relevant for more severe TBI where it may not be medically realistic for function to be completely restored. Turner-Stokes and colleagues conclude, Problems following acquired brain injury vary. Consequently, different interventions and combinations of interventions are required to meet the needs of patients with different problems. Those with moderate to severe brain injury benefit from routine follow-up so their needs for rehabilitation can be assessed. Patients discharged from in-patient rehabilitation benefit from access to out-patient or community-based services appropriate to their needs. In this case, the patient has a history of TBI, with speech, cognitive and physical disabilities. Given that current medical literature supports the use of rehabilitation and access to outpatient services for patients with varying degrees of TBI, the services at issue were and are medically indicated. Therefore, outpatient day neurologic rehabilitation provided by Centre for Neuro Skills San Francisco were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in neurology 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.