Professional Problem 2: Benjamin Dover
Benjamin Dover, a 42-year-old college professor, experienced weakness in his right arm while moving a bookcase in his office. He dismissed the passing weakness. Forty-five minutes later he again experienced right arm weakness, but this time it was accompanied by dizziness, nausea and difficulty walking. He made his way to the employee lounge and laid down on the sofa to rest. When questioned a short time later by a co-worker about his pale appearance, Ben attempted to answer the man but his reply was garbled and was produced with great effort. Ben was aware that he had given an incomprehensible verbal response, but he appeared to understand what was said to him. He fell to the floor during his attempt to get up from the sofa. Fortunately, the co-worker responded quickly by calling EMS.
Mr. Dover was transported to the nearest medical center 90 minutes away, receiving medical attention enroute. At the MedicalCenter, attempts at stabilization and a diagnostic work-up were begun. Shortly after his admission to the ICU, his condition worsened. He lost consciousness. His muscle weakness on his right side increased to the point where his upper extremity was flaccid and the lower extremity showed only proximal spontaneous movement. He was unable to be roused, even with sternal rub. The right side of his face lost muscle tone and began to droop, causing an asymmetry in his facial appearance. Ben did not require a respirator. He was put on anti-coagulants and monitored closely.
Over the course of the next few days, Ben gradually regained consciousness and became more alert. He was able to respond to his name and simple motor commands, and reliably responded to painful stimulation. He was confused by more complex verbal commands and was frequently unable to carry these out. Ben continued to produce vocalizations only with great effort and was unable to name visually presented pictures of objects. Ben was able to say “Damn it!” and “Way to go” smoothly and with little effort. Ben used these expressions regularly during his hospital stay in almost all situations or settings in what was obviously an attempt to communicate. When asked specifically to do so on neurological exam, he could sing the first few lines of the “Star Spangled Banner”. PT, OT, and SLP were ordered, and a neuropsychological consultation was written with a focus upon describing Ben’s functional cognitive state. He began to attempt to get out of bed, especially when incontinent (bowel and bladder, the latter required placing a Foley catheter). During ambulation training, Ben displayed unawareness of where he placed his right lower extremity during standing and transfers from WC to various surfaces. He was able to locate his right leg visually when cued, but would often roll over onto his arm in bed and get it caught in bedrails and wheelchair spokes. Ben required mod-max assist with ADLs and self-care, and total assist with transfers. He could stand for 20-30 second intervals with max assist of 2 persons. The neuropsychological. evaluation revealed nonfluent aphasia with intact comprehension, and relatively mild impairment of verbal memory. Verbal reasoning was also impaired. He showed mild right visual neglect (cue compensatable), right hemiparesis (UE>LE), and via astute observation during a PT session, right proprioceptive impairment regarding limb position in space. Ben, despite his numerous limitations, displayed a strong positive effort to improve in therapies. As he was pronounced medically stable on day 9 of his acute hospital stay, Ben Dover was referred to the Dewey, Cheatem, and Howe Rural Rehab Center 35 miles distant for comprehensive inpatient rehabilitation.
Mr. Dover lives with his 39-year-old wife Eileen and his 10-year-old son Tip and his 14 year-old daughter Rolle. Eileen is employed as a junior high teacher. Ben’s university had just negotiated a new health insurance contract and Ben has not dealt with this company before, nor had he updated his records in over four years. Due to a variety of errors in documentation, the newly-hired rehab admissions case manager did not receive pre-authorization for Ben’s admission. We are now on the third day of admission and the insurance company is denying payment for Ben’s ongoing rehab stay citing lack of proper pre-authorization. You have been asked, along with members of your team, to appeal this decision.
You are to formulate a specific rehabilitation plan for Ben for purposes of preparing an insurance appeal. What services does he need and for how many sessions should he be approved? What arguments can you make to the insurance company that rehabilitation is needed and will be beneficial?