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. The Plan denied your request. The Plan says the 
enrollee's wound care requires only wound VAC care x3 weekly and IV antibiotics. The enrollee's care can be 
provided in her acute inpatient facility. The Plan will recommend that the enrollee continue receiving care in 
the acute care facility for completion of the antibiotics and management of her other conditions. 
 
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 the enrollee presented to the hospital from a skilled nursing facility on October 13, 
2020 with a change in mental status and sepsis due to a worsening diabetic foot ulcer on her right foot. She has 
a past medical history of angina, diabetic neuropathy, poorly controlled DM, asthma, sleep apnea, GERD, renal 
transplant in 2016, and a recent hospitalization in August 2020 for hydronephrosis of her transplanted kidney. 
She had an MRI of the right foot which showed osteomyelitis of the posterior calcaneus. She was taken to the 
operating room on October 16, 2020 and underwent debridement of the right heel and a right partial 
calcanectomy. She has a wound VAC on the right heal in place with wound VAC changes three times a week. 
There are no plans for further surgery. She is to offload the heel with a Rooke boot when supine. Her bone 
cultures grew CRE Klebsiella pneumonia and VRE. She is currently on IV Daptomycin and IV Vabomere 
(meropenem/vaborbactam). Both antibiotics have a last scheduled dose date of November 4, 2020. There is no 
documentation provided necessitating admission to a LTACH. The enrollee still requires acute level of care 
hospital services and is receiving appropriate care at the present acute care hospital. The review has determined 
that the enrollee does not require services at the LTACH that are not available at the acute care hospital where 
she 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.