Intracranial Hemorrhage: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for a speech-generating device.Traumatic brain injuries (TBIs) are caused by an injury to the head and may cause temporary problems with normal brain function. Symptoms may be physical, such as headache and blurred vision, and cognitive in nature, such as change in consciousness, problems with memory, and/or issues with speech and sensation. Speech-generating devices have been increasingly used in patients with traumatic brain injury and resulting issues with communication. Speech rehabilitation is one of the most important rehabilitation targets after traumatic brain injury. A study revealed that speech-assistance devices allow severely impaired patients to communicate basic needs, improve their health and quality of life, and allow for better communication with their health providers.

A 45-year-old male has requested acute rehabilitation care for treatment of his medical condition status post intracranial hemorrhage with right sided hemiparesis. Findings: The physician reviewer found that it is generally agreed that a patient meets guidelines for acute inpatient rehabilitation when the following conditions are met: 1) Requires close physician supervision in order to care for multiple complex medical conditions; 2) requires the coordinated care of skilled therapists from multiple disciplines; 3) has the ability to participate in an intensive rehabilitation program and progress toward defined goals at a predictable and reasonable rate; 4) requires inpatient care and 24-hour rehabilitation nursing care; 5) could not achieve similar functional recovery in a less intensive setting. In the case under review, the patient sustained a severe brain injury secondary to ICH.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for non-emergency air, and associated ground ambulance, transportation services. At issue is whether the non-emergency air, and associated ground ambulance, transportation services were medically necessary for the treatment of this patient.The records indicate that this patient was admitted to the hospital after presenting to the emergency department with intracranial hemorrhage and fractures to the right femur, first rib, T1 transverse, and clavicle due to a motor vehicle accident. The patient required placement of a ventriculostomy and then a left decompressive hemicraniectomy as well as intramedullary nail fixation of the right femur.

Nature of Statutory Criteria/Case Summary: An enrollee has requested continued acute rehabilitation services for treatment of the enrollee’s intracranial hemorrhage (ICH) status post craniotomy. Findings: The physician reviewer found that the documentation does not support the requested continued acute rehabilitation services as medically necessary for treatment of this patient’s medical condition. The records do not indicate that the patient’s condition and functional status are such that the patient can reasonably be expected to make measurable improvement within a prescribed period of time as a result of the intensive rehabilitation therapy program, or that the services will be of practical value to improve the patient’s functional capacity or adaptation to impairments.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for intracranial hemorrhage was denied, the published record says the denial is worth fighting.