Trau Brain Inj Prog denials: what the review data shows

Where the denial was overturned

Findings: The physician reviewer found that The patient has requested authorization and coverage for full day speech, physical, and occupational therapies performed for up to four hours per day, five days per week. Current medical literature supports the use of rehabilitation in the context of traumatic brain injury (TBI). Researchers conclude regarding the effects of physical therapy interventions on balance impairments in individuals with TBI, “The evidence about the effects of the physical therapy interventions in improving the balance ability post-TBI was limited.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for outpatient day neurologic rehabilitation provided by Centre for Neuro Skills San Francisco. Vos and colleagues report that traumatic brain injury (TBI) is among the most frequent neurological disorders. Marklund and colleagues note extended time frames for the recovery process, which for patients with the most severe TBI may continue over months or even years. The authors quote the World Health Organization (WHO) definition for rehabilitation as, “A set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment.” The authors further note that brain injury rehabilitation promotes recovery through three main approaches.

Where the denial was upheld

Physician 1The patient is a 56-year-old male who experienced a head injury in July 2003. He showed mild cognitive deficits upon neuropsychological testing. The submitted records indicate the patient received speech therapy. He currently has a mild cognitive deficit. The patient consulted a neuropsychologist who recommended cognitive rehabilitation therapy. The Health Plan has denied authorization for cognitive rehabilitation therapy on the basis that it is considered investigational.Upon review of the submitted records it appears the patient’s cognitive issues are mild. Cognitive rehabilitation therapy was not ordered by the patient’s physician who has been directing the patient’s neurologic care. Cognitive rehabilitation in this setting is unlikely to be more effective than continued standard therapy.

The patient is a 30-year-old male who was noted as of 3/23/03 to be in a vegetative state. He was responsive to noxious stimuli. He had no eye opening and followed no commands. Per the physician’s note of 4/12/03, the patient had spontaneous eye opening, was non-verbal, and had increased tone in all four extremities. Upon admission to an eight-week coma rehabilitation program on 4/22/03, the patient exhibited the following: spontaneous eye opening, no tracking, disconjugate gaze, inability to follow directions, decorticate posturing on the left side, decerebrate on the right side, and no spontaneous motor movement. The patient was returned to acute care on 5/2/03 for repair of a colon perforation and returned to rehabilitation on 5/9/03. He remained at the same level of functioning. As of 7/16/03, there was no change in the patient’s condition.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Trau Brain Inj Progwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.