Inpatient Rehabilitation denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for inpatient rehabilitation.Findings: Three out of three physician reviewers found that the requested treatment of inpatient rehabilitation is likely to be more beneficial than any available standard treatment for the patient’s medical condition, complex regional pain syndrome in both feet and both hands.A review by Weissman and Uziel considered current treatment options for Pediatric complex regional pain syndrome (CRPS) and concluded that exercise and physical therapy are the main treatment cornerstones of all pediatric CRPS patients.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for rehabilitation services.One medical study found that patients with moderate-to-severe traumatic brain injury showed improvements in function after 90 days. Further improvement was observed after 180 days among the severely disabled group. Another study concluded that “continued specialized inpatient services following acute inpatient rehabilitation for individuals with moderate-to-severe traumatic brain injury can reduce the level of dependency and enhance the likelihood of return to community living.” The records reflect that this patient sustained a severe traumatic brain injury. The patient is only minimally able to move his hands and legs and is unable to speak or respond verbally.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for inpatient rehabilitation. Spinal cord injury can result in profound functional impairments generally requiring complex, individualized rehabilitative measures. The patient in this case sustained severe trauma to her spine, with clear clinical indications of paraplegia, as well as trauma to right lower extremity, due to a fall. There is ongoing loss of volitional motor function in the lower limbs, which is acute in nature. The patient is in need of rehabilitation to address functional deficits in light of this development. There is also a question of whether the patient has control of bowels and bladder. The patient’s course has been significantly complicated by psychiatric condition and cognitive impairments, including poor insight into patient’s condition.

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for inpatient rehabilitation services. The Health Plan has denied this request indicating that the requested inpatient rehabilitation services were not medically necessary for treatment of the patient’s medical condition. The submitted documentation does not support that the services at issue were medically necessary. In this case, the patient sustained multiple injuries to his body and brain as a result of aortic dissection and accompanying stroke. He underwent emergent surgical repair of the dissection and had subsequent sternal precautions. His stroke-related deficits were relatively mild and he recovered significant motor function. The patient’s hospital course was complicated by urinary retention, which required persistent intermittent catheterization.

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