Diagnosis:
Central Nervous System/ Neuromuscular Disorder
Treatment:
Skilled Nursing Facility
Health Plan:
Highmark
Decision:
Upheld upheld
Appeal Type:
Medical necessity
Gender:
Female
Age Range:
50-59
Decision Year:
2022
Appeal Agent:
Kepro dba IMEDECS
Case Number:
202112-144753
Summary

Diagnosis: Subacute hemorrhage (SAH). Treatment: Sub-Acute Rehabilitation. The insurer denied Sub-Acute Rehabilitation. The denial was upheld. The patient is a female who has a diagnosis of complications from a brain bleed. The rehabilitation stay was primarily for the complications of a brain bleed, specifically a subacute hemorrhage (SAH). The patient's other diagnoses at time of admission include, essential hypertension, alcohol abuse, cerebellar stroke syndrome, reduced mobility, fatigue, weakness, abnormalities of gait and mobility, unsteadiness on feet, radiculopathy of both cervical and lumbar region, cerebrovascular disease, reduced mobility, limitations of activities due to disability, nontraumatic intracerebral hemorrhage, hemiplegia and hemiparesis affecting left side, gastro-esophageal reflux disease, major depressive disorder, lipoprotein deficiency, chronic embolism and thrombosis of vein, and degenerative disease of nervous system. Physician documentation documents left arm weakness and minimal left leg weakness which is rated by physician on manual muscle testing as 4/5 strength of left upper extremity and 4 plus (+)/5 strength of left lower extremity. At issue is the medical necessity of Sub-Acute Rehabilitation. The health plan's determination of medical necessity is upheld in whole. The requested health service/treatment of Sub-Acute Rehabilitation is not medically necessary for this patient. Based on available documentation and the diagnosis being treated, continued Sub-Acute Rehabilitation is not medically necessary to achieve health and functional goals. The patient achieved level of function appropriate for discharge according to the documentation. This included minimal assistance for dressing and bed mobility. The patient was walking 300 feet with a cane and up 12 stairs. The patient was not on intravenous fluids, antibiotics, or enteral feeds. The patient did not have complex wound care. She was tolerating wound care and had well-controlled pain. Therefore, the requested health service/treatment of Sub-Acute Rehabilitation is not medically necessary.

References

1)https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-ML…. 2)https://www.medicare.gov/coverage/inpatient-rehabilitation-care. 3)Rundek T, Sacco RL. Prognosis after Stroke. In Mohr JP et al eds. Stroke, Seventh edition, 2021.