Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/circulatory Problems
Treatment: Skilled Nursing Facility-Acute Rehabilitation Facility

Diagnosis: Cardiac/circulatory Problems-Subarachnoid hemorrhage (SAH)
Treatment: Skilled Nursing Facility- Acute rehabilitation Facility

The health plan denied continued stay in acute rehabilitation facility as not medically necessary. 

The reviewer has upheld in whole the health plan's determination. 

The patient has a history of subarachnoid hemorrhage, DVT (deep venous thrombosis), and pulmonary embolism. He was initially treated with inpatient acute hospital admission with nausea and vomiting. He was diagnosed with subarachnoid hemorrhage. He developed obstructive hydrocephalus and was treated with medications and surgical placement of a ventricular drain. He developed hyponatremia and DVT in his upper extremities. He was transferred to inpatient rehabilitation but required transfer back to the acute care hospital due to pulmonary embolism and lower extremity DVT. He also had paroxysmal atrial fibrillation with aberrancy, and SIADH (syndrome of inappropriate anti-diuretic hormone), anemia, and hypertension. After stabilization in the acute care hospital, he was transferred back to the acute rehabilitation facility.

Within a reasonable degree of medical certainty, the requested health service/treatment of acute rehabilitation facility is not medically necessary for this patient. Inpatient rehabilitation level of care stay for the dates in question is not medically necessary as there was no documentation of significant improvement in strength, pain levels, range of motion, function, bathing, feeding, dressing, bed mobility, sitting tolerance, standing tolerance, toileting, transfers, gait, mobility, speech, cognitive function, or range of motion during the time frame. The peer-reviewed medical literature in the United States at this time would not include inpatient rehabilitation level of care stay. Further the medical standard of care does not support inpatient rehabilitation level of care stay. Milliman Care Guidelines (MCG) criteria for Inpatient rehabilitation facility (IRF) admission and ongoing care includes physician monitoring at least 3 days per week by a licensed physician determined to have specialized rehabilitation training and experience. MCG IRF criteria also includes goals for measurable improvement such as the nature and degree of improvement, time expected for achievement, and functional improvement anticipated to be practical, ongoing, and sustainable. Therapy is required at least 3 hours per day for 5 days per week and at least 15 hours per week over 7 consecutive days. The patient does not require skilled nursing services or skilled rehab services. Pain is well controlled, vital signs are stable, and intravenous (IV) fluids or antibiotics are not necessary, and therefore skilled nursing is not necessary. MCG criteria for IRF admission have not been met as there is no need for skilled nursing or skilled rehab in the setting of pain that is under control, no wound care needs, no IV fluid/antibiotic needs, stable vital signs, and no documentation of functional improvement that is anticipated to be practical, ongoing, and sustainable during the time frame in question.