Stroke denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for skilled nursing facility (SNF) services including physical therapy (PT) for 5 days/week x 1 hour/day until the enrollee is able to self-transfer to a wheelchair and wheels himself around, is able to self-transfer to a shower chair (and back to another chair), be able to walk on his own and be able to transfer assistance to home care; speech therapy (ST) for 5 days/week x 1 hour/day, until the enrollee is able to eat and swallow without aspiration risk (to get rid of the PEG-tube), be able to transfer assistance to home care, and speak enough to communicate and occupational therapy (OT) for 5 days/week x 30 minutes/day, until the enrollee is able to feed himself, to have control of his hands, be able to dress himself, brush his teeth and possibly be a…

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement and prospective authorization and coverage for acute rehabilitation services, or in the alternative, skilled nursing facility (SNF) level of care services. The records indicate that this patient has a history of diabetes mellitus type II, hypertension, and chronic kidney disease. The patient was admitted to the hospital for a stroke with left-sided hemiparesis, dysarthria, and dysphagia due to an occlusion of the right posterior cerebral artery. The patient underwent a thrombectomy and the hospital stay was notable for a urinary tract infection requiring antibiotics. The patient was admitted to acute inpatient rehabilitation. The patient’s acute inpatient rehabilitation stay was notable for acute diverticulitis, and he was started on prophylactic antibiotics.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient sustained a stroke, which affected his motor and sensory systems on the left side. He has been treated with outpatient therapy since August 2016, which has included therapeutic exercise, therapeutic activities, and neuromuscular re-education. From August 2016 to December 2016, the patient attended therapy that was aimed at decreasing his impairments, improving left-sided motor control, and improving his overall functioning. The patient was noted to be less fearful using his left lower limb for tasks such as standing in the kitchen and dressing himself. Decreased left shoulder tightness and inconsistent improvements in active assisted shoulder flexion were noted. There had been no improvements in active movements of his left hand. His left hand was tight, and he was not consistently wearing his left wrist-hand orthosis.

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

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving stroke, then check the rights and deadlines that apply to your plan.