Ischemic Stroke: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the computed tomography (CT) perfusion with contrast. Findings: The physician reviewer found that the acute management of strokes has undergone a fundamental change in the last several years. Typically, a patient presents with stroke symptoms, and a decision must quickly be made regarding whether thrombolytic therapy is indicated. This might include venous administration of tissue plasminogen activator (tPA), intra-arterial administration of tPA, or even surgical/radiologic thrombectomy. However, there is an upper time limit in which tPA is most effective. Thus, a provider must distinguish whether the suspected stroke is ischemic or hemorrhagic. This is generally easily accomplished with a simple unenhanced CT scan of the brain.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient skilled nursing facility (SNF) services and physical therapy, occupational therapy, and speech therapy services provided at Broadway by the Sea. Functional impairments due to acquired brain insults such as stroke can be severe to profound. One researcher notes that rehabilitation is an important aspect of the continuum of care in strokes, and that successful rehabilitation involves understanding the natural history of stroke recovery and a multidisciplinary approach to identify and treat common poststroke sequelae. A researcher notes that patients may improve spontaneously within the first three months and then more slowly in the coming year.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility services, including physical therapy twice daily, occupational therapy twice weekly, and speech therapy. Admission to a SNF is appropriate for patients with conditions that require observation, evaluation of treatment plans, and updating of orders by a physician along with constantly available skilled nursing services. Skilled nursing services may include wound management, tracheostomy care, bowel and bladder training, tube feeding, and the administration of intravenous (IV) medications or medications that cannot be self-administered safely. Skilled nursing observation may include regular monitoring of vital signs, skin in the setting of wounds, and intake and output.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services. Functional impairments due to acquired brain insults such as stroke can be severe to profound. While functional recovery may be amenable to natural recovery processes and rehabilitative measures, the extent of initial injury is a major determinant of functional outcomes as it defines the residual neuronal reservoir that is capable of engaging in recovery (Alawieh, et al.). As noted in the medical literature, most of the significant neurological and functional recovery following a stroke occurs in the early stages after stroke and gains are slower in subsequent stages (Kubis). There is a general consensus that initiating rehabilitative measures earlier in the post-stroke course enhances outcomes (Belagaje, et al.).

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 ischemic stroke was denied, the published record says the denial is worth fighting.