Disclosures: Travis E. Quinn, MD: Nothing to disclose

Case Description: A patient with past medical history of dense spastic left hemiplegia secondary to temporal arteriovenous malformation status-post resection in 2004 underwent a left total hip arthroplasty (THA) for displaced left femoral neck fracture following a fall. The patient required frequent tone management modifications; a few months prior baclofen was discontinued by Urology due to urinary retention. The patient subsequently had increased falls at home and an eventual hip fracture requiring THA on his spastic hemiparetic side. After surgery, he required maximal assistance for transfers, standing, and lower body dressing with painful increase in left-sided spasticity. His wife’s private Blue Cross insurer with secondary Medicare, denied the admission stating the patient did not require regular medical intervention.

Setting: Inpatient Rehabilitation Facility (IRF)

Patient: 63-year-old male with left-sided spastic hemiplegia

Assessment/Results: PM&R consult recommended IRF admission for impaired mobility and self-care as well as for medical management of his post-operative, increased spasticity inhibiting progress. A peer-to-peer was held to advocate for the patient. There was expectation for measurable improvement in function, and the patient was approved for admission to IRF. During IRF admission, spasticity required management with dantrolene sodium and incobotulinumtoxinA injections. Urinary retention was avoided. Function improved to contact-guard for ambulation with a quad cane and AFO during the patient’s 15-day stay.

Discussion: This case highlights factors that are missed when insurance policies have diagnosis-specific denials. Physiatric care is based on creating an individualized assessment and plan. The severity of this patient’s spasticity, accompanied by pain management needs and history of urinary retention, required regular physiatric management to achieve functional status allowing return to home.

Conclusion: Physiatrists must work together with policy-makers and insurance companies to ensure quality care and favorable outcomes for patients with disabilities. During discrepancies, physiatrists must advocate for IRF admission when appropriate, often surmounting industry barriers.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/recent-insurance-carrier-practices-related-to-inpatient-rehabilitation-irf-admissions/