Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission 
criteria under CMS guidelines. The Plan denied your request. The Plan says the records do not support that the 
enrollee requires the special long term acute care available at an LTACH or that the enrollee will require long-
term acute care for more than 25 days. Therefore, it is not medically necessary for admission to an LTACH. 
The enrollee can safely receive this care in another setting, such as a skilled nursing facility or at home with 
home health services until a definitive course of treatment is undertaken. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has osteomyelitis with ulcers of both feet (left worse than right). The 
enrollee has been receiving treatment of this condition since May 27, 2020 when he was hospitalized followed 
by skilled nursing facility admission from June 2, 2020 through June 20, 2020. The treatment included wound 
debridement, wound care, and intravenous antibiotics. He has been receiving home health nursing service with 
twice weekly wound care with outpatient podiatry management with intermittent local debridement. He was 
recently evaluated in the podiatrists office on   October 12, 2020 when transmetatarsal amputation of the left foot was recommended to address the limited 
healing of the left foot. He is not currently receiving oral or intravenous antibiotics. The requested LTACH 
admission is not medically necessary because the records do not support that the enrollee requires the special 
long term acute care available at an LTACH or that he will require long-term acute care for more than 25 days 
The review has determined that the enrollee does not require services at the LTACH that are not available at 
the acute care hospital where he is currently receiving care.  
 
 
 
 
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the health plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.