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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acute rehabilitation from a facility accredited by the Commission on Accreditation of Rehabilitation Facilities to treat spinal cord injury, that include the following comprehensive, interdisciplinary system integrating services: recreational therapy, participation in wheelchair sports, robotic assisted rehabilitation, rehabilitation with the Lokomat, rehabilitation with an exoskeleton, wheelchair evaluation, selection and fitting, bone loss class/education, gait analysis, respiratory training, simulated home living experience with caregiver training, transitional care between inpatient, outpatient, and wellness center, discharge plans with integration/consideration of social support and the assistance as needed/available at home, vocational re-integration programs/classes, classes on pressure relief, classes on bowel/bladder, classes on autonomic dysreflexia, comprehensive psycho-social services, daily diet support, pathokinesiology, community outings, participation in a community re-integration program, integrative assistive technology, classes for sex with a spinal cord injury, and exercise classes for spinal cord injury. Spinal cord injury can result in profound functional impairments requiring complex, individualized rehabilitative measures. This patient sustained acute tetraplegia due to acute trauma. He has been essentially dependent for all self-care and mobility, but is cognitively intact and able to participate and tolerate therapies.  He requires complicated rehabilitation services to address functional deficits in multiple areas of impairment, including self-care, mobility, neurogenic bladder and neurogenic bowels. There have been recent medical complications, including aspiration pneumonia and anemia, and he is at risk for developing other complications on account of his spinal cord injury. At this stage, the patient does require acute inpatient rehabilitation for intensive and highly complex rehabilitation services, while being closely followed by a physiatrist. This level of care can be provided at the in-network acute inpatient rehabilitation facility, which is a large rehabilitation facility with a specific program in inpatient spinal cord injury rehabilitation. There is no medical necessity of acute inpatient rehabilitation at the requested acute inpatient rehabilitation facility. Thus, the requested acute rehabilitation from a facility accredited by the Commission on Accreditation of Rehabilitation Facilities to treat spinal cord injury, that include the following comprehensive, interdisciplinary system integrating services: recreational therapy, participation in wheelchair sports, robotic assisted rehabilitation, rehabilitation with the Lokomat, rehabilitation with an exoskeleton, wheelchair evaluation, selection and fitting, bone loss class/education, gait analysis, respiratory training, simulated home living experience with caregiver training, transitional care between inpatient, outpatient, and wellness center, discharge plans with integration/consideration of social support and the assistance as needed/available at home, vocational re-integration programs/classes, classes on pressure relief, classes on bowel/bladder, classes on autonomic dysreflexia, comprehensive psycho-social services, daily diet support, pathokinesiology, community outings, participation in a community re-integration program, integrative assistive technology, classes for sex with a spinal cord injury, and exercise classes for spinal cord injury is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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.