Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for methicillin-resistant staphylococcus aureus (MRSA) assessment, neurology assessment, magnetic resonance imaging (MRI) scan, Ross Information Processing Assessment, Second Edition (RIPA-2) testing, and daily physical therapy. Findings:  The physician reviewer found that with regards to the request for MRSA assessment, active surveillance consists of performing screening cultures (of the nares, oropharynx, and/or perineum) to identify asymptomatic patients who are colonized with antibiotic-resistant bacteria. This is typically performed in a hospital with the goal of prevention of spread of MRSA to other patients.  Active surveillance cultures appear to be most useful in the setting of hospital outbreaks and among patients at high risk for MRSA carriage.  In this case, the patient is residing in a skilled nursing facility while receiving rehabilitation services. The documentation supports that her function has improved and plateaued.  She is clinically stable, without active infection.  The documentation does not support screening for MRSA, as the patient is residing in a skilled nursing facility without evidence of an outbreak or clinically active disease.  With regards to neurology assessment, the patient is status post traumatic brain injury with intracerebral hemorrhage and left sided hemiparesis.  She has stabilized and has been receiving inpatient rehabilitation services, with improvement in her function and mobility.  The patient has had intermittent encephalopathy due to end stage liver disease with resulting hyperammonemia.  This condition is being cared for by her primary care providers.  The documentation does not support that there are any ongoing neurological symptoms or conditions which require a consultation with a neurologist.  The Health Plan has authorized a comprehensive treatment plan, and the patient is being cared for by a primary care provider and rehabilitation specialists.  With regards to MRI scan, the patient has had repeat imaging of the brain.  The patient had an intracerebral hemorrhage in July 2016, with resulting hemiparesis. Repeat computed tomography of the brain was stable with encephalomalacia that is expected after an intracerebral hemorrhage with traumatic brain injury.  The documentation shows that the patient has improved with regards to her function and medical status.  There are no new neurologic deficits or symptoms of recurrent neurological insult.  With regards to the cognitive assessment tool, RIPA-2, neuropsychological testing is not helpful in most patients with post-concussion syndromes after a traumatic brain injury has resulted in cognitive impairment.  In this case, the patient had a traumatic brain injury resulting in an intracerebral hemorrhage.  The documentation shows that the patient had MoCA testing, and again more recently, with a decrease in score of 24/30 to 11/30. The patient has had a clear cognitive decline, and the use of further cognitive assessment by RIPA-2 is not indicated.  With regards to daily physical therapy, the documentation shows that the patient is able to ambulate up to 50 feet with mild to moderate assistance.  The patient appears to have had a plateau in function with inpatient rehabilitation services.  She was discharged from skilled daily rehabilitation services and was residing at a custodial level of care at the skilled nursing facility.  The patient is planned for discharge home with her husband with home health services for assistance with activities of daily living and can receive further therapy at a lower level of care. The patient was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation and treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.