Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Skilled Nursing Facility. 

The insurer denied Acute Inpatient Rehabilitation. 
The denial is overturned. 

The patient is a male who suffered cardiac arrest with resultant hypoxic ischemic brain injury. His wife administered chest compressions after finding him with persistent coughing and making gurgling sounds. When emergency medical services (EMS) arrived, he was found to be in ventricular fibrillation arrest and initiated Advanced Cardiac Life Support (ACLS) protocol including intubation for an estimated 20 minutes before arriving at the Emergency Department (ED). He was again found to be pulseless in the emergency department (ED) and had 6 more minutes of resuscitation before achieving return of spontaneous circulation. 

The impression was myocardial infarction that led to his cardiac arrest. 
Prospect of long-term neurological recovery was felt to be unclear. It was observed later that the patient appeared significantly improved though probability of return to baseline was guarded. Aggressive physical and occupational therapies were recommended. Electroencephalogram (EEG) showed diffuse moderate diffuse slowing consistent with hypoxic ischemic brain injury. Head computed tomography (CT) results showed no acute territorial infarction, hemorrhage of mass effect while noting it was a mildly to moderately limited study. The magnetic resonance imaging (MRI) of the brain showed moderately enlarged lateral and third ventricles and bilateral periventricular fluid attenuated inversion recovery (FLAIR) hyperintensities as well as hyperintense signals in the cortex of the insula and temporal lobes. 
The discharge recommendation was acute rehabilitation. 
The issue at hand is whether Acute Inpatient Rehabilitation is medically necessary. 

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

The requested health service/treatment of Acute Inpatient Rehabilitation is medically necessary for this patient.
Acute Inpatient Rehabilitation is medically necessary as it provides a service that provides the best opportunity for maximal recovery and functional gains. The basis for denial of acute brain injury rehabilitation was inability to participate. However, the therapy notes from the acute care hospital do not support this. In fact, the patient appeared to be participating, was not resisting, and was making neurologic and functional progress, thereby demonstrating the prospects of benefiting from acute rehabilitation. Further strengthening his candidacy was the fact that he is relatively young in terms of age and was independent pre-injury and co-owned an electrical contracting company.
Brain injury acute rehabilitation centers specialize in this patient's condition. Therefore, this service is clinically appropriate and required for the direct care and treatment and management of the condition. It offers a more intensive rehabilitation program. Literature supports the benefits of multi-disciplinary rehabilitation for acquired brain injury in adults of working age (16 to 65 years of age) in that intensive rehabilitation appears to lead to earlier gains. (1) The traumatic brain injury (TBI) literature also supports early onset and more intensive neurorehabilitation to promote functional recovery in moderate to severe TBI patients. (2) Lastly, there is literature to support similar functional gains and outcomes in severe anoxic brain injury patients compared to severe TBI patients. (3) Given the benefits of acute neurorehabilitation, it can be concluded that the patient's situation would be adversely affected if the service was not provided.
Therefore, the requested health service/treatment of Acute Inpatient Rehabilitation is medically necessary.