Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nonaccidental head trauma.
Treatment: Continued Inpatient Rehabilitation OT (occupational therapy)/PT (physical therapy) and Speech.
The insurer denied: Continued Inpatient Rehabilitation OT (occupational therapy)/PT (physical therapy) and Speech.
The denial is upheld.

This patient is a young female child with a history of nonaccidental head trauma. The child has been brought to the local emergency department (ED) with altered mental status. Clinical evaluation at the local hospital yielded physical and neuroradiological evidence of trauma and neurological deficits. The child has been initially admitted to acute care hospital intensive care unit where she was diagnosed with nonaccidental brain trauma and had initially been treated for seizure disorder, autonomic dysfunction, dysphagia, mild stenosis of the spinal canal at L (lumbar) 1 level, moderate stenosis at L2-L3 level and severe stenosis at L4-S (sacral) 1 level. The child required ventilatory support, nutritional augmentation via nasogastric tube. The child required video electroencephalography (EEG) monitoring. Spasticity management has been initiated. 

Following clinical stabilization, the child had been transferred to inpatient pediatric rehabilitation. There are significant social issues in this case requiring Administration for Child Services (ACS) and foster care referral and investigation. Review of ongoing clinical records revealed resolution of a variety of symptoms including dysphagia, autonomic instability, and constipation. The child demonstrated steady progress in rehabilitation but continued to exhibit evidence of left hemiplegia, alternating exotropia, left VII nerve palsy, and seizure disorder requiring medication management. 

Following review by the health plan, continuous stay at the rehabilitation hospital has been denied and a lower level of care has been suggested. The medical plan determined that skilled needs are no longer needed for this child. An appeal has been filed in response to the denial on behalf of this child by the hospital based on the facts that the facility is a specialty care treatment center for children with complex medical needs, ongoing treatment is in fact medically necessary, the facility would be remiss and certainly act below the standards of care were to discharge this child without appropriate place to live, safety of discharge has been uncertain, continuous need for ongoing rehabilitation has been postulated. Discharge planning continues to be challenging due to social circumstances.

The proposed Continued Inpatient Rehabilitation Occupational Therapy (OT) / Physical Therapy (PT) and Speech is not medically necessary.

In this case, this child with neurological deficits stemming from nonaccidental brain injury exhibited great degree of clinical improvement and some evidence of functional advancement. The proposed extent of skilled services as well as duration of services are no longer needed in inpatient settings. Therefore, the medical necessity for acute inpatient services as well as skilled nursing services are no longer needed.

Based on the review of medical records, the child continues to exhibit chronic medical conditions (seizure disorder, history of brain injury) as well as rehabilitation / habilitation needs as result of the severe nonaccidental brain injury. This child's clinical needs have been improved during inpatient stay and have been resolved.  Therefore, there is no evidence of medical necessity for continuation of acute inpatient stay and there is a lack of evidence of skilled nursing needs. At the same time, the child continues to require skilled, physical, occupational and speech therapy needs that can be provided in a less acute setting. 

Of note - in this case there are many confounding factors in relation to social barriers for discharge including but not limited to foster care referral and ongoing Administration for Child Service (ACS) cases. Safety of discharge planning has to be insured to less acute settings.