Diagnosis: Head trauma, initial encounter

Treatment: Continued inpatient rehabilitation level of care

The insurer denied coverage for continued inpatient rehabilitation level of care.

The denial is upheld.

This patient was admitted for gunshot wounds to the head, chest and left groin. He underwent a hemi-craniotomy. He was transferred to acute inpatient rehabilitation. He was readmitted to the acute hospital for repair of cranial incision dehiscence. He was transferred back to acute inpatient rehabilitation and has received physical therapy (PT), occupational therapy (OT), and speech therapy (ST) as well as psychological care.

From a physical medicine and rehabilitation perspective as well as a reasonable degree of medical certainty, the patient could have been transferred to a lower-level care, including outpatient rehabilitation services. The clinical records clearly document the patient was at a functional level that no longer required inpatient rehabilitation level of care:

1) According to the Psychiatry Brief Progress Note, the patient was "Stable from that outlined in initial psychiatric consultation note. No acute safety concerns." 2) According to the Summary report, nursing service report indicated the patient had no limitations for mobility, was cleared to ambulate and remained "free of falls." 3) According to the physical therapy note, the patient was able to "ascend and descend 2 flights of stairs demonstrating a reciprocal LE [lower extremity] pattern without a handrail independently." 4) In occupational therapy, the patient had long since achieved independence with activities of daily living including dressing, hygiene and grooming. 5) The clinical records also indicate there were no acute medical or complicated nursing issues to support the medical necessity of inpatient rehabilitation level of care.

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in this particular case. From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, inpatient rehabilitation level of care was not medically necessary.

The insurer's denial of coverage for continued inpatient rehabilitation level of care is upheld. Medical necessity is not substantiated.