Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tendinitis of the Right Ankle. 
Treatment: 18 days of Acute Inpatient Rehabilitation. 

The insurer denied coverage for 18 days of acute inpatient rehabilitation. 

The denial is overturned. 

This case involves a patient with a history of asthma and seasonal allergies.  The patient sustained an injury to the right foot.  He did not receive treatment for his right foot injury.  He subsequently sustained an injury to his right ankle months later after being hit by a baseball.  At that time, he sought treatment, diagnostic testing, and outpatient physical therapy.  He was diagnosed with tendinitis of the right ankle.  He wore a cam boot for 4 weeks, attended physical therapy twice a week for 8 weeks, had acupuncture, utilized a transcutaneous electrical nerve stimulator, and utilized medications.  After treatment, he continued to have pain, difficulty walking, and swelling.  The provider noted that since the patient had been unable to ambulate normally.  He had chronic pain in his right foot and ankle.  At times, he was unable to ambulate.  The provider stated that the patient's symptoms were severe.  The patient required specialized attention.  The patient was seen for initial consultation.  The patient endorsed ongoing right ankle and right foot pain.  The pain was worsened with activity.  The patient reported that he was not able to participate in activities that he once enjoyed.  The exam findings of the right ankle noted edema, tenderness to palpation, decreased range of motion, and no active inversion or eversion of the ankle secondary to pain and edema.  The patient was hypersensitive to multiple trigger and non-trigger points.  The patient had physical deconditioning and complex regional pain syndrome of the right lower extremity.  The patient had functional decline.  He had failed numerous amounts of outpatient modalities of treatment.  Due to the patient's ongoing functional decline, admission to the inpatient pain rehabilitation program was recommended.  The patient had major functional disability.  The patient required extensive psychological or behavioral therapy to cope with his pain.  The patient needed to be temporarily removed from a detrimental home situation to refocus.  He was able to sit to stand transfer with no assistance.  However, he performed this with decreased weight shift on the right lower extremity.  His gait was asymmetrical.  He was only weightbearing through the heel on the right lower extremity.  There was no push-off through toes.  He had decreased stance time.  He could not complete stair testing secondary to pain.  There was minimal weight shift on the right when standing.  The patient had not been walking properly or functioning in an age-appropriate manner.  He had a slow gait pattern with decreased weightbearing.  He could not participate in baseball and required the use of an elevator at school.  He was admitted for acute inpatient rehabilitation.  The patient was discharged. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.   The 18 days of acute inpatient rehabilitation is considered medically necessary for this patient. 

According to the medical literature, "Intensive inpatient rehabilitation is effective for children with complex regional pain syndrome."   In this case, the claimant has already trialed alternative lower levels of treatment including bracing, physical therapy, acupuncture, electrical stimulation, and medications.  He continued to have severe functional decline due to physical deconditioning and complex regional pain syndrome of the right lower extremity.  The claimant would not have significant symptom improvement at lower levels of care.  Ongoing care at a lower level would result in continuation of debility and further deconditioning.  Thus, the treatment was medically necessary.  As such, the denial of coverage for 18 days of acute inpatient rehabilitation was inappropriate and is overturned.  

The insurer's denial of coverage for 18 days of acute inpatient rehabilitation is overturned. Medical Necessity is substantiated.