MEDICAL POLICY POLICY TITLE POLICY NUMBER ACUTE INPATIENT REHABILITATION MP-8.003

Transcription

1 Original Issue Date (Created): July 1, 2002 Most Recent Review Date (Revised): Effective Date: May 27, 2008 May 1, RETIRED I. DESCRIPTION/BACKGROUND Inpatient rehabilitation hospitals provide an intensive multidisciplinary approach to rehabilitation services for injured and disabled individuals to restore lost function following illness or accidental injury. II. DEFINITIONS ACUTE REHABILITATION HOSPITAL is a facility or distinct part of a facility that is licensed or approved under state and local law as an acute specialty hospital providing a comprehensive inpatient rehabilitation program. The facility must be approved by the Joint Commission on the Accreditation of Healthcare Organizations, or by the Commission on Accreditation of Rehabilitation Facilities, and be primarily engaged in providing skilled rehabilitation services on an inpatient basis. Skilled rehabilitation services consist of the combined use of medical, social, educational and vocational services to enable members disabled by disease or injury to achieve the highest possible level of functional ability. Skilled rehabilitation services are provided by or under the supervision of an organized staff of physicians. Continuous nursing services are provided by or under the supervision of a registered nurse. DAILY REHABILITATION SERVICES are skilled rehabilitation services that must be required and provided no less than five (5) days per week. INTENSE LEVEL OF REHABILITATION SERVICES is one in which the patient requires and receives at least three (3) hours of skilled rehabilitation services in any combination of modalities. MULTIDISCIPLINARY TEAM usually includes a physician, rehabilitation nurse, social worker and/or psychologist and therapists involved in the patient s care. At a minimum, the team must include a physician, rehabilitation nurse and a therapist. Page 1

2 SKILLED REHABILITATION SERVICES are those services which are furnished pursuant to a physician order that: Require the skills of qualified technical or professional health personnel such as physical therapists, occupational therapists and speech pathologists; Must be provided directly by or under the supervision of these skilled nursing or rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result. III. POLICY The medical necessity and appropriateness of Acute Rehabilitation Hospital inpatient admission determinations will be made following the guidelines set forth in this policy and further described in the Center for Medicare & Medicaid Services (CMS)/Medicare guidelines as documented in the Medicare Benefit Policy Manual, Chapter 1 -Inpatient Hospital Services Covered Under Part A, Section 110- Inpatient Hospital Stays for Rehabilitation Care. For inpatient care in an Acute Rehabilitation Hospital to be considered medically necessary all of the following criteria must be met: The patient s condition must require the close medical supervision and twenty-four (24) hour per day availability of a physician who specializes or is experienced in the field of rehabilitation; The patient s condition requires twenty-four (24) hours per day availability of a registered nurse that specializes or is experienced in the field of rehabilitation; The patient must require an intense level of rehabilitation services on a daily basis; The rehabilitation plan of care must utilize a multidisciplinary approach to delivery of care and services; The rehabilitation program must be a coordinated process that includes frequent periodic team conferences for assessment of progress, identification and resolution of impediments to progress and ongoing evaluation of the validity of the individualized patient goals; and Realistic, individualized patient goals must be established by the treatment team and must be attainable within a reasonable timeframe. Page 2

3 NOTE: Cognitive therapy is not addressed in this policy. Cognitive therapy is addressed in MP IV. Cross-Reference MP Cognitive Therapy MP Long Term Acute Care Hospital (LTACH) EXCLUSIONS Inpatient acute rehabilitation care and services are not considered medically necessary and an appropriate level of care when: The patient no longer demonstrates significant, consistent progress towards established goals; The care and services required to meet established goals can be provided in a less intensive setting; or Rehabilitation goals are achieved. 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. Page 3

4 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 Centers for Medicare and Medicaid Services (CMS) Medicare Benefit Policy Manual. Publication Chapter 1. Section 110-Inpatient Hospital Stays for Rehabilitation Care. [Website]: Accessed March 27, Hopman WM, Verner J. Quality of life during and after inpatient stroke rehabilitation. Stroke Mar;34(3): Epub 2003 Feb 13. VIII. PRODUCT VARIATIONS [N] = No product variation, policy applies as stated [Y] = Standard product coverage varies from application of this policy, see below [N] CHIP POS [N] PPO [N] HMO [N] CHIP HMO [N] SeniorBlue [N] SeniorBlue PPO [N] Indemnity [N] SpecialCare [N] POS [N] FEP HMO [N] FEP PPO 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 4

5 IX. POLICY HISTORY CAC 5/25/04 CAC 6/28/05 CAC 7/26/05 CAC 6/27/06 CAC 6/26/06 CAC 6/26/07 CAC 5/27/08 Policy approved for retirement effective 5/1/2008. Page 5