Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Primary central nervous system (CNS) tumors
Treatment: Acute Rehabilitation (Inpatient Medical Rehabilitation)
The insurer denied the Acute Rehabilitation (Inpatient Medical Rehabilitation).
The denial is overturned.

The patient is a female child with medical history significant for unspecified PNET (primitive neuroectodermal tumor) diagnosed status post surgical resection with chemotherapy and radiotherapy, chronic diabetes insipidus, chronic respiratory failure status post tracheostomy placement on trach collar, chronic dysphagia status post gastrostomy tube placement, seizure disorder that returned to the hospital after being hospitalized at another facility for persistent fevers. She had been admitted twice before. 

She was clinically stable on tracheostomy collar round-the-clock. She had no respiratory issues. She was tolerating her gastrostomy tube feedings. She had no reported seizures. She was scheduled for follow-up with Orthopedic Surgery via telemedicine for right distal femur fracture the following day. She was also scheduled for an airway evaluation pending negative COVID (coronavirus) testing.

In terms of therapy goals, at that time she was tolerating sitting up in the wheelchair up to two hours twice daily. She was working on left ankle mobility but was noted to have increased tone compared to previous. She was working on passive range of motion in the upper extremities but had not made significant progress from previous. She had an inconsistent response to oral motor stimulation and ability to tolerate secretions. She had not made any progress on ability to wear the Passy-Muir speaking valve during waking hours. At this time, family was in the midst of training, and the child had been referred to a skilled nursing facility. She had fever, attributed to being central in origin. She was treated symptomatically, not given stress steroids. There were no further fevers. Later on in the month, she also had her tracheostomy tube downsized, with plans to continue downsizing as tolerated. The summary included discharge planning: send home if able to get private duty nursing versus admit to a skilled nursing facility.

Yes, ongoing acute rehabilitation services are medically necessary and appropriate for this child.

The health plan has denied because the child is no longer making progress in therapy.

This young child suffered greatly following her diagnosis of cancer, with subsequent chronic respiratory failure and chronic feeding failure. She is both tracheostomy and gastrostomy tube dependent. She has been placed at the current facility because she no longer requires acute inpatient admission but her clinical status and care are too complicated for discharge home without round-the-clock skilled nursing services or transfer to a skilled nursing facility. She receives the same level of nursing care that she received in the acute care hospital compounded by rehabilitation services, her best chance at improvement, albeit slow improvement. She has been making progress, but she is fighting both her ongoing illness as well as the disabilities that she has as a result. The type of acute rehabilitation scenario that is created at the facility is customized to each individual, with the goal of optimal growth and development and return to as close to baseline as possible. Concurrently, they seek the best placement for each patient, either at home with family or a skilled nursing facility as a subacute patient. The requested ongoing acute rehabilitation is medically necessary and appropriate for this child as the staff at the facility attempt with their skilled services to promote the best recovery possible.

No, the health plan did not act reasonably. Please see the discussion above.