Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for any or all of the daily outpatient rehabilitation treatment services including speech therapy, occupational therapy, and physical therapy with education and counseling provided by Centre for Neuro Skills. Giustini and colleagues note that one of the main considerations when dealing with traumatic or nontraumatic brain injury is the complexity of the rehabilitation process. Smania and colleagues report that while functional and cognitive impairments in patients with severe traumatic, cerebrovascular, or anoxic acquired brain injury (ABI) may improve with time and rehabilitation, patients with cerebrovascular and anoxic ABI may have a more challenging clinical course. Skilled therapy services following an acute injury may promote recovery, maximize function given impairments, and transition patients to an independent program when feasible, or train caregivers for supervising a brain injury survivor's convalescence in the community. In the setting of severe brain injuries, deficits may remain severe despite intensive rehabilitation measures. In this case, the patient suffered a traumatic brain injury. She underwent both acute and subacute inpatient rehabilitation programs. She is physically independent with her basic self-care and mobility but remains sufficiently impaired with respect to cognitive function, physical function and safety awareness that she continues to require supervision, redirection and physical assistance for instrumental ADLs and community level mobility. She lacks the faculties at this time for independent living, gainful employment or meaningfully returning to university as a student. The  documentation shows that the patient has made modest and incremental functional progress, however her overall status is largely unchanged, and the gains were not a function of the intensity of her therapies. In this clinical setting, ongoing daily outpatient rehabilitation is not expected to marginally and positively impact the patients clinical or functional course or outcomes beyond any further recovery she may potentially experience with a program overseen by her caregivers, to include physical and mental exercises, and the passage of time. Therefore, all of the daily outpatient rehabilitation treatment services including speech therapy, occupational therapy, and physical therapy with education and counseling provided by Centre for Neuro Skills were and are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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.