All requests for admission or transfer to an LTACH facility must be reviewed by a plan medical director.

Transcription

1 Original Issue Date (Created): September 20, 2005 Most Recent Review Date (Revised): May 24, 2011 Effective Date: I. POLICY July 1, RETIRED All requests for admission or transfer to an LTACH facility must be reviewed by a plan medical director. Care and services in an LTACH may be considered medically necessary for the following categories of patients described in detail in Paragraph A-D below. A. Prolonged Ventilator Weaning LTACH admission may be considered medically necessary for patients determined to be ventilator dependent as defined by: A minimum of one week failed ventilator weaning in an ICU or acute care facility supervised by a pulmonary or intensivist specialty physician, or The inability to attempt weaning due to an underlying medical condition such as pneumothorax or flail chest, and Weaning potential is not precluded by an underlying condition such as brain death. The following criteria must also be met: The patient must be medically stable so that transfer from an acute care hospital setting to an acute LTACH setting is medically feasible as determined by the following conditions being satisfied: 1. The patient does not require ongoing multi-specialty care or consultation;, and 2. The patient is neurologically stable, and 3. The patient is not actively bleeding or requiring blood products, and 4. All major diagnoses are established and no significant diagnostic testing requiring an acute hospital setting are present; and 5. The patient has not been determined to be permanently ventilator dependent. The ability to wean the patient from the ventilator would be enhanced by the equipment and staff available in an LTACH. Page 1

2 B. Complex Wound Care LTACH admission may be considered medically necessary for complex stage III and IV wounds with need for intensive assessment and treatment that meet the following criteria: Complex dressings and therapies are expected to require at least 25 days to complete; and Significant co-morbidities exist that require additional support unavailable at an acute care hospital or at a lower level of care such as a skilled nursing facility; and Treatment is precluded at an acute care hospital due to: 1. Lack of on site wound care services and specialty care; or 2. Lack of high technology equipment (i.e., wound vac, etc.). Treatment is precluded at a skilled nursing facility due to: 1. Lack of on site wound care services and specialty care; or 2. Lack of high technology equipment; or 3. Nursing care exceeds 6.5 hours per 24-hour period. C. Medically Complex Patients Care at an acute LTACH may be considered medically necessary for patients with complex medical problems who cannot be managed in the acute hospital setting or at a lower level of care due to lack of either high technology equipment or specialty care. In addition, the length of stay should be expected to exceed 25 days. In order to be considered eligible, the patient must not have any of the following: Active bleeding or requirement for frequent blood products Blood pressure instability or significant cardiac arrhythmia Requirement for ongoing multiple specialty consultation that would require an acute hospital setting. D. Neurological and/or Musculoskeletal Disorders Requiring Comprehensive Medical and/or Rehabilitation Care Care at an acute LTACH may be considered medically necessary for patients requiring comprehensive rehabilitation such as brain and spinal cord injuries, multiple trauma cases, joint replacements, etc., whose care cannot be administered at an acute rehabilitation setting. Page 2

3 Medical necessity and appropriateness of all LTACH admissions, transfers, and approved lengths of stay will be made in accordance with program-specific benefits and the guidelines set forth in this policy. In some cases, a member may meet the criteria for admission to an LTACH; however, if in the opinion of the reviewing medical director, care can be best provided by keeping the member at the acute hospital care level, then admission to the LTACH may be considered not medically necessary. If care can be provided in the setting of an inpatient rehabilitation facility or a skilled nursing facility, then LTACH admission is considered not medically necessary. Continued stay determinations will be made by a concurrent care nurse in coordination with a Plan medical director. When a member in an LTACH has progressed to a point where ongoing inpatient care is still required but can be provided at a skilled nursing facility or inpatient rehabilitation facility, continuation of stay in the LTACH setting may be considered not medically necessary. Patients with any of the following are not considered eligible for treatment in an LTACH setting: Requirement for ongoing multiple specialty consultation that would require an acute hospital setting; Ancillary services such as dialysis in the setting of acute renal failure (dialysis for chronic renal failure is an eligible condition), ultra filtration, plasmaphoresis, etc., that may be better done in an acute hospital setting; Active bleeding or requirement for frequent blood products; or Blood pressure instability or significant cardiac arrhythmia. Cross-reference MP Ambulance and Other Medical Transport Services Page 3

4 II. PRODUCT VARIATIONS [N] = No product variation, policy applies as stated [Y] = Standard product coverage varies from application of this policy, see below [N] Capital Cares 4 Kids [N] PPO [N] HMO [N] Indemnity [N] SpecialCare [N] POS [N] SeniorBlue HMO [N] FEP PPO [N] SeniorBlue PPO III. DESCRIPTION/BACKGROUND An LTACH is an acute care hospital designed to provide specialized care for medically complex patients who are critically ill with multi-system complications and/or multisystem failures and who would otherwise require an extended stay in an acute care setting. Some LTACHs are freestanding facilities while others are hospitals within a hospital. To qualify as an LTACH under Capital BlueCross programs, an institution must be certified by CMS as an LTACH. Many LTACH patients come from acute care hospital intensive care units and continue to require long-term hospitalization and rehabilitation care in an acute care setting. Some of these patients have multiple co-morbid conditions complicating their primary diagnosis or they have ventilator-dependent conditions. Ventilator weaning is the process of gradual removal of ventilator support from a ventilated patient. While the majority of patients can be weaned from a ventilator without difficulty, for others the process is slower, requiring more time and care. IV. DEFINITIONS PREAUTHORIZATION: a process by which an established set of criteria is applied to a request for services to determine appropriateness of setting and medical necessity. Preauthorization review occurs prior to the performance of non-emergent services, thereby providing a decision regarding authorization of a covered benefit before the service is rendered. Page 4

5 V. BENEFIT VARIATIONS The existence of this medical policy does not mean that this service is a covered benefit under the member's contract. Benefit determinations should be based in all cases on the applicable contract language. Medical policies do not constitute a description of benefits. A member s individual or group customer benefits govern which services are covered, which are excluded, and which are subject to benefit limits and which require preauthorization. Members and providers should consult the member s benefit information or contact Capital for benefit information. VI. DISCLAIMER Capital s medical policies are developed to assist in administering a member s benefits, do not constitute medical advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any medical policy related to their coverage or condition with their provider and consult their benefit information to determine if the service is covered. If there is a discrepancy between this medical policy and a member s benefit information, the benefit information will govern. Capital considers the information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law. VII. REFERENCES Acute Long Term Hospital Association (ALTHA). [Website]: Accessed February 17, American Hospital Association. Long Term Care Hospitals. [Website]: Accessed February 17, Centers for Medicare and Medicaid. Long Term Care Hospital PPS. [Website]: Accessed February 17, 2011 Munoz-Price LS. Long-Term Acute Care Hospitals. Clinical Infectious Diseases 2009;DOI: / Scheinhorn, David J. MD, FCCP; Hassenpflug, Meg Stearn MS, RD; Votto, John J. DO, FCCP; Chao, David C. MD, FCCP; Epstein, Scott K. MD, FCCP; Doig, Gordon S. PhD; Knight, E Bert MD, FCCP; Petrak, Richard A. MD; for the Ventilation Outcomes Study Group + Post-ICU Mechanical Ventilation at 23 Long-term Care Hospitals*: A Multicenter Outcomes Study. Chest. 131(1):85-93, January Thakar CV, Quate-Operacz M, Leonard AC, Eckman MH. Outcomes of hemodialysis patients in a long-term care hospital setting: a single-center study. Am J Kidney Dis Feb;55(2): Page 5

6 VIII. CODING INFORMATION Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement. Specific procedure coding does not apply to this policy. IX. POLICY HISTORY MP CAC 3/29/05 CAC 3/28/06 CAC 3/27/07 CAC 5/27/08 CAC 5/26/09 Consensus CAC 5/25/10 Consensus CAC 4/26/11 Consensus Policy approved for retirement effective 7/1/2012. The content from the medical poicy has now been transitioned (unchanged) into an Administrative Bulletin Guideline, and the guideline, as was the case for the medical policy, is not a guarantee of either approval or coverage. Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. Page 6