Acute Rehabilitation denials in California external review

What the reviewers wrote

Where the denial was overturned

The parent of an 18-year-old male enrollee has requested continued acute rehabilitation services for the treatment of the enrollee’s traumatic brain injury. Findings: The physician reviewer found that this patient is demonstrating continued progress in acute rehabilitation and has potential for additional improvement. Appropriate rehabilitation goals are identified and include hygiene, grooming and self-care skills. Acute rehabilitation services should continue for an additional four weeks.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for continued acute rehabilitation with neurology and cardiology follow up, as deemed necessary by the current inpatient treating neurologist and cardiologist, as well as one hour of occupational therapy, speech therapy, and physical therapy Monday through Friday. Functional impairments due to a cerebral stroke, whether ischemic or hemorrhagic, can be severe to profound. The extent of initial injury is oftentimes a major determinant of functional outcomes (Alawieh, et al.). Most of a patient’s significant neurological and functional recovery occurs in the early stages after a stroke and gains are slower to come in the subsequent stages (Kubis). Initiating intensive rehabilitative measures earlier in the post-stroke course has been shown to enhance patient health outcomes.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage skilled nursing facility (SNF) services and acute rehabilitation level of care services. Minor spontaneous spinal hematomas occurring in the thoracic spine may be managed with observation and conservative measures. However, larger spinal hematomas with significant neurological compromise generally require surgical intervention with spinal decompression and hematoma evacuation. Functional impairments related to residual paraplegia and neurogenic bowel and bladder require complex, individualized rehabilitative measures. This patient’s records document that she developed acute paraparesis due to a hematoma following anticoagulation for a pulmonary embolus. The patient underwent spinal decompression and hematoma evacuation.

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 Acute Rehabilitation, then check the rights and deadlines that apply to your plan.