UTILIZATION MANAGEMENT GUIDELINE
*Medicare has a policy.
An acute Inpatient Rehabilitation (IPR) program may be considered medically necessary when ALL of the following criteria are met:
Acute IPR may be considered not medically necessary when:
Common conditions/services that may be considered not medically necessary for IPR level of care include, but are not limited to:
Clinical Indications for Transition of Care
Transition from an inpatient rehabilitation facility (IPR) to an alternate level of care may be considered medically necessary when ONE of the following criteria are met:
In addition, the following discharge criteria should be met for a safe transition to a lower level of care:
NOTE: Coverage for acute inpatient rehabilitation (IPR) services is subject to the limits and conditions of the member benefit plan.
Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage.
This guideline incorporates clinical, facility, and care based indicators to determine the appropriateness of admission to inpatient rehabilitation (IPR) level of care. In addition, transition of care guidelines are given as indicators to determine if the patient may be appropriate for safe transfer from the inpatient rehabilitation facility to home or an alternate setting.
Patients may require acute IPR after amputation, stroke, cardiac events, or other exacerbations of conditions that result in significant functional deficits. The patient admitted to acute rehabilitation care must be capable of fully participating in the IPR program. The goal of acute rehabilitation care is to help patients who are physically or cognitively impaired to achieve or regain their maximum functional potential for mobility, self-care and independent living. Complete independence may not be an ultimate goal. However, a measureable improvement in functional ability must be achievable.
Acute IPR care is provided by a multidisciplinary team as part of an intensive integrated program at an inpatient rehabilitation facility (IRF) or a specialized unit within a hospital. The program is directed by a physiatrist or rehabilitation physician specialist. The services may include, but are not limited to combinations of the following: physical therapy, occupational therapy, speech therapy, cognitive therapy, respiratory therapy, psychology services, prosthetic/orthotic services, and rehabilitation nursing. Patients admitted to the facility or hospital rehabilitation unit usually spend 3 to 6 hours a day in a structured rehabilitation program, or at least 15 hours over 5 days.
Definition of Terms
New policy, add to Utilization Management section.
Replace Policy. Rewritten for clarification. Policy title updated with the word “inpatient”. Policy wording revised for clarification of active participation. Related policy added for Skilled Nursing Care in the Home. Policy guideline section revised for clarification of criteria used to review clinical information and when coverage stops. Definitions added for FIM scale and physiatrist, other definitions sorted alphabetically. Reference 1 added; other references renumbered. Policy statement intent unchanged.
Replace policy. Added a note stating MCG’s are proprietary and the process to request a copy.
Update Related Policies; change title of policy 10.01.500.
Annual Review. Added not medically necessary criteria to the policy section. Policy revised based on a literature search through July 2014. Reference to using MCG as a tool to guide determinations is removed. Reference 3 added; others renumbered/removed. Policy statements changed as noted. Codes removed; revenue and diagnosis codes are not reviewed with relationship to this policy.
Policy converted to Utilization Management Guideline addressing transition of care for inpatient rehabilitation. No change in coverage intent; considered medically necessary when criteria in this guideline are met. Updates are effective January 1, 2015.
Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).