Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy/Childbirth/Premature Birth - Feeding problems
Treatment: Inpatient Hospital - Acute Rehabilitation Facility
The health plan denied the requested health service/treatment of Inpatient Hospital -  Acute Rehabilitation Facility as not medically necessary.
The health plan's determination is upheld.

The patient has a diagnosis of feeding problems. Per the medical records, the patient has additional diagnoses of prematurity (ruptured membranes at 20 weeks), respiratory failure, prolonged intensive care unit stay, atrial septal defect, bronchopulmonary dysplasia, hypothyroid, and gastroesophageal reflux disease (GERD). The patient was weaned from supplemental oxygen by time of transfer. Per the physician's letter, the patient's "weight and height fluctuated." The letter states that the reason for the additional stay was that nursing was not available until that date.
During the time period in question, it was not medically necessary for the patient to be in an acute rehabilitation facility. 
Continued care in an acute rehabilitation facility is medically necessary for those who: 1) are participating in intensive therapy (generally a minimum of 15 hours per week); 2) are showing measurable improvement in their functioning; 3) are making progress in therapy (physical therapy, occupational therapy, and/or speech/language therapy); and 4) need continued treatment at this level of care.
Since the physician's letter states that the facility is not an acute rehabilitation facility and is considered LTACH (Long Term Acute Care Hospital), the criteria for LTACH were additionally considered in this review of the appeal. The care provided by an LTACH is hospital-based care, and as such, admission requires documentation that patients have a complicated course of recovery that requires prolonged hospitalization. Treatment at an LTACH may be required in the face of complex medical issues that meet the criteria of two or more medically active conditions that require: three or more interventions including intravenous medications, continuous intravenous fluids, total parenteral nutrition or peripheral parenteral nutrition, and blood products; at least one physician visit per day; frequent diagnostic services; and active participation in therapies at least 5 days per week. Beyond general complex medical issues, the other two major categories that may require an LTACH level of care include complex wound/burns and mechanical ventilation weaning.
During the time period in question, the patient did not meet the criteria of patient needs requiring the LTACH level of care. The reason stated by the physician is, "due to lack of capable skilled nursing in the community within the insurance network, the patient could not go home." Discharge planning for patients, whether pediatric or adult, often requires post-discharge skilled nursing in the community. Planning for this need is part of the discharge planning process. Medical necessity for an inpatient stay pertains to the patient's medical needs that necessitate the inpatient stay. Per documentation in the Pediatric Interim Progress Note, the patient's home medications had arrived from the previous hospital, and there was a plan to teach the use of the home feeding pump to the mother depending on mother's schedule. Per the Pediatric Interim Progress Note, the home care vendor had already been identified. It is not documented precisely when the facility had identified the nursing staff vendor or when the facility had begun to seek home care agencies for the discharge. The discharge plan to home for a medically fragile infant such as this one would have appropriately been in the active planning process for several weeks in advance of the discharge date. 
The continued stay was not medically necessary. Delays by the institution in planning for the expected needs at discharge does not constitute medical necessity for prolongation of the stay.