Please Help Revise Question & Answer Guide (With Explanation)

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Original Question

Please help me revise this rough draft letter to an insurance company to appeal a medical denial for inpatient rehab. The member was denied due to the following reasons: 1. You do not need 3 hours of therapy for 5 days a week 2. You do not an interdisciplinary team 3. a rehab physician monitoring you at least 3 times per week 4. You do not need physical and occupational therapy HOWEVER Given the clinical documentation shown all these reasons are inappropriate per cms guidelines. Clinical documentation clearly shows the patient meets all of these criterias for a safe discharge back into the community. PLease help me with a appeal letter in response to this denial. I am attaching my rough draft below Attached you will find the Appointment of Representative form signed by the patient, preadmission evaluation for acute rehab with an accepting PM&R approval and supporting clinicals documenting the referring facility’s recommended and preferred comprehensive acute rehabilitation. The above-mentioned patient’s initial request for inpatient rehabilitation services was denied due to medical necessity with a recommendation of lower level of care such as a skilled nursing facility. The care this patient needs would not be adequately delivered in a skilled nursing facility. This patient is a 62-year-old male who has just suffered from a Large left MCA distrubutuion infarct with multiple regions of hemorrhagic transformatio n eithin themidportion of the infarct, left distal posterior occulcation and now has aphasia. Patient is at a critical juncture in his recovery procress. Patient is nonverbal since onset of his recent CVA and presents now with mulitiple deficits that can only be properly met at a higher level of care. Patients following impairments include functional limitations, weakness, impaired balancem decreased safety awareness, gait instability, decreased lower extremity function,abornomal tone, impaired ensurece and self care skills. Patient is at acute hospital waiting for this denial to be overturned for inpatient rehab. Patient also has a history COPD, depression, hypertension, substance use disorder, possible scheizophrenia, hepatitis c infection and chronic c HFrEF (20%). Due to his complexneurological condition and significant decrease in functional ability requiring specialized therapy. It is imperative that this member get the correct care for maximum function and to avoid another hospitalization. His needs will not be properly met at a lower level of care given all of the clinical documenation provided. The referring physician at the acute hospital has strongly recommended acute inpatient rehabilitation for which he was assessed and accepted by the specialized doctor. This patient’s medical management is far too complex for the limited clinical and therapeutic environment in a lower level of care. The above-mentioned patient requires inpatient rehabilitation in the form of Physical, speech and Occupational Therapy to improve strength, eating, speaking and endurance, improve balance, and reduce the patient’s fall risk. It is imperative that he receives this oversight from inpatient rehabilitation due to the clinical complications he has already shown thus far. He is at risk for multiple injuries if not given the proper care. During his admission and in addition to rehabilitation, we will focus intensely on functional mobility, ADLs, education, diet, and safety training for both the patient and caregivers. This member meets CMS criteria for admission to acute inpatient rehabilitation. He is motivated and eager to have an opportunity to regain function and is looking forward to admission to Encompass Health to maximize his outcome. I have included a letter from directly from him per his request.

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