Diagnosis: Cerebral vascular accident (CVA).

Treatment: Inpatient rehabilitation admission.

The insurer denied coverage for an inpatient rehabilitation admission.

The denial is upheld.

This is a man with hypertension, diabetes, cerebral vascular accident (CVA) with right hemiplegia. He was status post a thrombectomy, tracheostomy, and a PEG (percutaneous endoscopic gastrostomy) tube insertion. He was readmitted to the hospital for respiratory distress and then returned to the rehabilitation Center. Under review is the medical necessity of continued inpatient rehabilitation. The patient was initially appropriate for inpatient rehabilitation. His ability to perform activities of daily living and functional mobility had the potential for significant improvement with intensive acute inpatient therapy. According to the occupational therapy note, the patient required moderate to maximal assistance for dressing and toileting. He required moderate assistance for bed mobility and transfers in physical therapy. He was only able to ambulate approximately 10 feet with a rolling walker and minimal assistance. However, more recent clinical notes were not available for review to support the medical necessity of continued inpatient rehabilitation.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient in this particular case. Considerations include the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendations and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and/or associations. All decisions are evidence-based.

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, an inpatient rehabilitation admission, was not medically necessary.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an inpatient rehabilitation is upheld. Medical Necessity is not substantiated.