Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 
The patient is a 65-year-old male with a history of seizures due to epilepsy for which brain surgery was performed in March 2015. In 2015, he reportedly sustained a subarachnoid hemorrhage. He became dependent on mechanical ventilation and received a tracheostomy. He received an enterostomy tube for feeding. The patient was transferred to a skilled nursing facility (SNF) on 7/9/15. On 9/12/15, he was transferred back to the hospital and on 9/25/15, he returned to the SNF. On 1/10/16, he returned back to the hospital for unspecified reasons. On 1/30/16, he returned to the SNF with diagnoses including chronic respiratory failure, tracheostomy, epilepsy, hyperlipidemia, chronic obstructive pulmonary disease (COPD), hyperglycemia, polyneuropathy, cerebellar ataxia, alcoholic liver disease, alcohol abuse, hypothyroidism, hypertension, gastroesophageal reflux disease (GERD), and urinary retention. He was receiving gastrostomy tube feeds. He had an indwelling urinary catheter. A pain management interview noted that the patient is alert, confused and disoriented. He was noted to be non-verbal. There was no pain at present. On examination, he had 2+ pitting edema. He required total assistance for self-care. On 3/11/16, physical therapy was discontinued. On 5/20/16, a consultation note indicated past history of hyperlipidemia, alcohol abuse and respiratory failure. He was alert and in no acute distress. There was atrophy and contractures. He was non-ambulatory. A left heel blister was noted. On 6/30/16, restorative nursing was ordered by the provider for passive range of motion of the upper and lower limbs. On 8/17/16, oral Levaquin antibiotics were ordered for the urinary tract infection. On 8/19/16, ertapenem intravenous (IV) antibiotics were ordered for the urinary tract infection. The providers notes from 9/2/16 through 10/14/16 document a stable clinical condition, awake neurological status, and review of lab test results. On 9/28/16, he was sent to the acute hospital for a change of gastrostomy tube. On 10/14/16, the provider noted that there was no fever or bleeding. The patient was tolerating tube feeds. Exam noted that he was awake. There was 1+ edema. On 10/16/16, Macrobid was ordered for a urinary tract infection. On 10/20/16, ertapenem IV antibiotics were ordered for the urinary tract infection. A letter from the provider dated 4/12/17 stated that the patient required respiratory support, multiple lab tests, seizure prophylaxis, tracheostomy care and additional medical interventions. The patients representative has requested reimbursement for the inpatient services provided at Goldstar and Beachwood Rehabilitations Centers provided from 10/30/15 through 1/10/16 and from 4/22/16 through 1/11/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary.Functional impairments due to acquired brain insults can improve with time including after subarachnoid hemorrhage (Navi, et al; Turner-Stokes, et al). The role of inpatient rehabilitative care for patients with significant functional deficits following acquired brain insults is relatively well-established in the medical literature (Langhorne, et al). In the present case, the patient was hospitalized with an acquired brain insult, due to various factors including surgery for a seizure disorder and subarachnoid hemorrhage. He eventually became alert, but non-verbal and confused. There are no indications in the available records that the patient was able to participate in therapies in a meaningful manner at any time during the time period under review, or that he made or was expected to make any significant functional progress. The records document that the patient had atrophy and contractures, was totally dependent for all self-care, and he received passive range of motion by restorative nursing. The services provided were on a long-term, maintenance basis, which are considered custodial in nature. Given these findings, the inpatient services provided at Goldstar and Beachwood Rehabilitations Centers provided from 10/30/15 through 1/10/16 and from 4/22/16 through 1/11/17 were not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.