Diagnosis: Prader Willi Syndrome

Treatment is continued acute rehabilitation (inpatient medical rehabilitation services)

The insurer denied coverage for continued acute rehabilitation (inpatient medical rehabilitation services)

The denial is overturned

The patient is a teenager with history of Prader Willi Syndrome. The patient has multiple medical problems including pneumonia, cellulitis of lower extremity, syncope, obstructive sleep apnea (OSA), status post (s/p) tracheostomy and on ventilator support, obesity, diabetes mellitus (DM), hypertension (HTN), and hypothyroidism. The patient was admitted to an Acute Rehab Facility for continuing care. The patient was receiving physical therapy (PT), occupational therapy (OT) and speech language pathology (SLP) therapies. In addition, the patient was requiring ventilatory support, respiratory treatments with Albuterol twice a day (BID), hypertonic saline BID, MetaNebs three times a day (TID) and also Flovent.

The patient was on ventilatory support with rate 14, FIO2 (fraction of inspired oxygen) 28 % and High PEEP (positive end-expiratory pressure) of 12 to prevent atelectasis.

This patient was cleared for discharge to a Long Term Care (LTC) for ongoing care. Multiple facilities refused to accept the patient due to a change in needs and ventilator requirements and complex medical needs. The patient's family was unable to take care of the patient due to access issues and complex medical needs and ventilator dependency which the family was unable to provide.

As per the last progress notes, the patient was receiving PT/OT and SLP therapies and was ventilator dependent.

There was no safe discharge plan in place. The patient needed to be placed in LTC, but no facility was available. The patient's family unable to care for the patient at home.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for continued acute rehabilitation (inpatient medical rehabilitation services) forward is substantiated.