Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Wound dehiscence
Treatment: Acute rehabilitation (inpatient medical rehabilitation)
The insurer denied acute rehabilitation (inpatient medical rehabilitation)
The determination is overturned.

The patient has a complex medical history including Proteus syndrome, resultant hypertrophy and malformation of his lower extremities and buttocks status post multiple extensive surgeries complicated by wound dehiscence, wound infection, anxiety, and depression. His social situation was also complicated by the recent loss of his mother from coronovirus 2019 (COVID-19) complications, resulting in new living arrangements with his estranged father.
He was initially admitted to the for wound dehiscence of the left foot following an orthopedic surgical procedure. He had undergone a left foot radical soft tissue resection with debridement and complex closure but the area became infected with subsequent dehiscence requiring return to the hospital and further surgical management. While under acute care, he was treated with both parenteral and enteral antibiotics under Infectious Disease guidance, completing full courses with improvement in both the wound as well as laboratory markers. Orthopedics recommended non-weight-bearing (NWB) of the left lower extremity until the wound was fully healed. He was closely followed by both Orthopedics and Plastic Surgery, going to the operating room (OR) for wound incision and drainage with wound vac placement. The wound vac was discontinued and he was transitioned to twice daily dressing changes.
He was transferred for ongoing wound care, dressing changes, pain control, and rehabilitation therapies for return of strength and ability to ambulate. Wound care continued with eventual application of Medi-Honey cream until the wound had fully healed. Because of his history of wound dehiscence and complicated/delayed recovery, he was monitored for an additional week to monitor for integrity of the wound with receiving ongoing rehabilitation therapies including ambulation. He was followed closely by Orthopedics during his stay and last seen in follow-up, in agreement with the plan for discharge home. Because of his history of anxiety and depression, his recent loss of his primary caregiver, and his significant change in social situation, he was also followed closely by Psychology and Psychiatry; outpatient support was strongly recommended. By the time he was discharged, he had achieved his baseline ability to ambulate. He had no fevers, no significant pain, and no signs or symptoms of infection.
At issue is the medical necessity of acute inpatient rehabilitation.
Acute rehabilitation (inpatient medical rehabilitation) was medically necessary for this patient.
Proteus syndrome is an extremely rare condition characterized by asymmetric overgrowth multiple tissues including skin, connective tissue, bones, nervous system, and eyes. The onset is typically in childhood with the more complex manifestations developing over time. Patients may experience macrodactyly deformities, unilateral hypertrophy, palmar or plantar cerebriform hyperplasia, subcutaneous tumors, verrucous nevus, exostosis, and vessel hamartomas. This syndrome affects more males than females and is evenly distributed amongst ethnicities. The feet seem to be disproportionately involved. Diagnosis is based on clinical manifestations and imaging. There are clinical criteria available for diagnosis. Treatment is related to the varied clinical features, often involving surgical treatment. Early intervention is vital to reduce extra malformations, disfiguring physical defects, and loss of movement, as well as to mitigate the enormous psychological burden on patients and their families.
This male child with Proteus syndrome has experienced numerous complications from his condition, including wound infection, wound dehiscence, need for further surgical intervention, and significant psychological trauma with the loss of his mother. He was hospitalized for a long time in the acute care setting with resultant deconditioning, and upon discharge from acute care was not yet ready to fully discharge to his home situation. He required ongoing daily wound care, therapies to regain strength and skills, and significant psychological support above and beyond what could be safely achieved in the fully outpatient setting. Because of the severity of his complications in the past with the resultant severe morbidity requiring additional surgeries and prolonged antibiotics and hospitalization, it was medically necessary and appropriate to monitor the wound site for integrity upon return to baseline levels of activity and ambulation without wound breakdown or infection.  In this case, the patient was receiving frequent aggressive rehabilitation services to allow for return to baseline functioning, wound care which included monitoring once the would had "healed" as he began to ambulate more (since he had suffered dehiscence previously), round the clock nursing services, frequent physician rounds, and ancillary medical services (eg psychology, psychiatry). This level of care is most consistent with acute care, including frequency of vital sign measurements, nursing interventions, physician interactions, and rehabilitation services. The last days of care were crucial to his full recovery and ability to safely return to the outpatient setting without increased risk of morbidity. The requested services were medically necessary and appropriate.