Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma/Injuries. 
Treatment: Skilled Nursing Facility. 

The insurer denied Acute Rehabilitation Facility. 
The denial is upheld. 

The patient is a male with a traumatic brain injury, skull fractures, subarachnoid hemorrhage, and cerebral edema admitted to the hospital surgical intensive care unit (SICU) and intubated. He was treated with right frontal burr hole and ventriculostomy, left frontal craniotomy and placement of monitor. He underwent bifrontal temporal decompressive craniotomy and replacement of external ventricular drainage (EVD). The EVD was removed. He was extubated. He underwent autologous bifrontal temporal cranioplasty. He developed acute mental status changes (AMS) and computed tomography (CT) scan of the head showed worsening hydrocephalus. 
He was admitted to Acute Inpatient Rehabilitation. He had significant waxing and waning of his mental status during hospitalization. He had visual hallucinations, paranoia, and loss orientation requiring restraints, anti-psychotic medication trial and titration with psychiatry recommendations. He also had sleep/wake dysfunction.
At issue is the medical necessity of the requested health service/treatment of Acute Rehabilitation Facility. 

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

The requested health service/treatment of Acute Rehabilitation Facility is not medically necessary for this patient. 
The patient was ambulating with a rolling walker 80-100 feet with contact guard/standby assistance. He had impaired insight and impaired safety awareness. There were cognitive impairments. He required contact guard for transfers. He required supervision for toileting and dressing. The speech therapy note stated that he had no pain. He had decreased safety awareness auditory comprehension deficit, verbal expression deficit, reading comprehension deficit, linguistic attention deficit, linguistic orientation deficit, linguistic memory deficit, linguistic organization deficit, and linguistic problem solving/reasoning deficit. He had no pain. He was confused, had poor judgment and poor safety awareness. He was able to walk 400 feet with a rolling walker and supervision. Mat mobility and transfers were with supervision. The occupational therapy note stated that he had back pain. He required supervision or touching assistance for upper body dressing, moderate assistance with putting on and taking off footwear, and supervision or touching assistance for transfers. He required contact guard for ambulation with a rolling walker. 
During the requested time frame, there was no documentation of significant improvement in pain levels, strength, range of motion, function, ambulation, transfers, bed mobility, upper extremity dressing, lower extremity dressing, hygiene, toileting, or feeding. The peer-reviewed medical literature in the United States at this time would not include the requested health service/treatment of Acute Rehabilitation Facility. Further, the generally accepted medical standard of care does not support the requested health service/treatment of Acute Rehabilitation Facility. 

Therefore, the Acute Rehabilitation Facility is not medically necessary.