Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke
Treatment: Continued Rehabilitation Facility
The insurer denied: Continued Rehabilitation Facility
The denial is partially overturned.

The patient is an adult right hand dominant male. He presented to the hospital after having woken up with right-sided weakness and dysarthria. He was found to have uncontrolled hypertension. Initial neuroimaging was unremarkable. The patient was transferred to a tertiary medical center for further evaluation and treatment. Follow up imaging showed an acute to subacute left medial medullary stroke, as well as chronic lacunar infarcts and signs suggestive of microangiopathic disease. There was no large vessel occlusion. He was also incidentally found to have diabetes mellitus (with hemoglobin A1c [glycated hemoglobin] elevated at 8.8) and a thyroid nodule concerning for malignancy. He was medically managed with permissive hypertension and pharmacotherapy (aspirin, clopidogrel, and a statin) for secondary stroke prophylaxis. He was started on insulin. An outpatient fine needle biopsy was planned for the thyroid nodule. 
Functionally, there was persistent dysarthria, dysphagia, and right hemiparesis.
The patient was transferred to an acute inpatient rehabilitation unit in the medical center. The patient's blood pressures were elevated. His beta blockers were increased. The patient's blood pressures remained elevated. Amlodipine was added. The patient's blood pressure was improved but still elevated. The plan was to increase his amlodipine further. The patient's amlodipine dose was increased. On the first date in question, the patient's blood pressure was improved. He was set up for bathing and dressing while seated, with contact guard assist to finish with his pants. He was contact guard assist for toileting. He was supervision to contact guard assist for transfers. He was ambulating 160 feet with a hemiwalker. He was doing better with right ankle dorsiflexion assist via Ace wrap or a temporary orthosis. He was negotiating stairs at contact guard assist. There was mild to moderate dysarthria. He was on a soft and bite sized solids diet with thickened liquids. The following day, the patient's blood pressure was improving. He was seen by a psychiatrist for depression. He was started on sertraline.
On the second date in question, the patient's gait was noted to be improved with an ankle foot orthosis. He was started on trazodone for insomnia. Following, the patient had no significant complaints. Blood pressure was 141/82. The patient's amlodipine was changed to nifedipine. On day #13, there were no complaints. He was awaiting transfer to a subacute facility. He underwent a swallowing study and cleared for a soft and bite sized solids diet with mildly thickened liquids. The day after, the patient's blood pressure remained somewhat elevated (151/78). On day #16, the patient was discharged from the acute inpatient rehabilitation facility to a subacute rehabilitation facility. 

The Continued Rehabilitation Facility was medically necessary, in part.

The acute inpatient rehabilitation stay remained medically necessary for the first 12 days. The stay after the first 12 days was not medically necessary at the acute inpatient rehabilitation level of care. The patient had sustained a stroke and also had newly diagnosed diabetes mellitus and hypertension. Initially, he was allowed permissive hypertension to allow for optimal blood flow to the stroke penumbra. Subsequently, the blood pressure management was tighter and required close physician follow up. His blood pressures were being monitored closely and his antihypertensive medications were being adjusted through the first 12 days. He was also being evaluated for depression by psychiatry, for poor sleep by the physician (with medication adjustment), and for his foot drop by the physician and therapists (with a decision made for an ankle foot orthosis). There were multiple issues being closely followed and managed. 
While he continued to have issues that required further follow up, medical care, and rehabilitation, further care could have been provided at the subacute rehabilitation level of care. This was the 
facility's plan, with the transfer occurring on day #16 due to administrative issues rather than medical and rehabilitative need.