Diagnosis: Parkinson's

Treatment is continued stay in the rehabilitation center

The insurer denied coverage for continued stay in the rehabilitation center

The denial is upheld

This is a male patient, who has a history of paranoid schizophrenia, Parkinson's, seizures, substance abuse, and deep vein thrombosis. He was admitted to a rehab center with decline in mobility, function, and self-care ability. He is now medically stable.

The patient is now mostly contact guard assist (CGA)-to-supervised for care. The patient has no complex wound care needs, or intravenous (IV) medication requirements. There are no nursing or therapy needs that are skilled and warranting a continued stay in the rehabilitation center as opposed to a lesser level of care (including home health care services). The patient's vital signs are stable. As such, the continued stay in the rehabilitation center is not considered medically necessary for this patient.

"Individuals with health conditions or injuries may require rehabilitation across the course of their lifespan. The timing and type of intervention that a rehabilitation provider selects depend greatly on several factors. These include the etiology and severity of the person's health condition, the prognosis, the way in which the person's condition affects the person's ability to function in the environment, as well as the individual's identified personal goals. Rehabilitation services may be delivered in any setting (including in hospitals and in communities), depending on individuals' needs and situation. " (Mills, T. et al 2017).

O'Brien, S. R., & Zhang, N. (2018) state "High intensity therapy was associated with more community discharges in comparison to the remaining intensity groups (hazard ratio, .84, .68, and .433 for medium-high, medium-low, and low intensity groups, respectively). More hospitalizations and deaths were found as therapy intensity decreased. Only high intensity therapy was associated with a 2-day shorter length of stay (incident rate ratio, .95). High intensity therapy was associated with desirable discharge outcomes and may shorten SNF (skilled nursing facility) length of stay"

The continued stay in the rehabilitation center is not considered medically necessary for this patient. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for continued stay in the rehabilitation center is upheld. Medical Necessity is not substantiated.