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 it is medically necessary. The Plan 
denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and is currently 
unstable for transfer to an LTACH. 
 
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 review indicates that the enrollee is a 67-year-old with a past medical history 
significant for cirrhosis complicated by spontaneous bacteria peritonitis, recurrent diverticular abscess and 
perforation, diet-controlled diabetes mellitus and hypertension who was admitted to the acute hospital on April 25th, 2023, with abdominal pain and found to have sepsis due to perforated sigmoid diverticulitis and multiple 
abscesses and possible aspiration pneumonia. The enrollee underwent colectomy with Hartman's procedure, 
appendectomy and enterectomy on April 27th. The enrollees course was complicated by altered mental status 
with acute on chronic hypoxic and hypercapnia respiratory failure requiring intubation on May 8th; chest cat 
scan obtained on May 7th showed moderate to large left pleural effusion with compressive atelectasis and chest 
x ray showed worsening airspace opacities. Tracheostomy placed on May 18th and nutrition is via nasogastric 
tube; the enrollee was deemed not a candidate for percutaneous endoscopic gastrostomy tube due to the 
presence of large volume ascites on May 17th. Chest x ray obtained on May 14th showed dense consolidation 
bibasilar left greater than right; status post bronchoscopy for mucous plugging; the enrollee completed 
antibiotics on May 17th. The enrollee was found to have a hemoglobin of 6.4 secondar to an upper 
gastrointestinal bleed requiring 1 unit transfusion on May 22nd. There is also concern for underlying muscular 
weakness with muscle biopsy obtained on May 22nd, pathology positive for possible myositis. Per clinical 
progress note from May 23rd: The enrollees last chest x ray showed no improvement in bilateral pulmonary 
opacities from progress note from May 17th. The enrollee hemoglobin is 6.9 and 1 unit packed red blood cell 
has been ordered with discussion with surgery for possible endoscopy. The enrollee is afebrile without 
leukocytosis and remain ventilator dependent on Pressure control 30% FIO2.  At the time of the request, the 
enrollee is medically unstable for transfer due to abnormal chest x ray findings, a lack of an updated chest 
imaging and ongoing gastrointestinal bleed with anemia with transfusion and possible endoscopy pending. 
 
LTACHs are certified under Medicare as short term acute care hospitals that have been excluded from the acute 
care hospital inpatient prospective payment system (PPS) in the Social Security Act, Section 1886(d)(1)(B)(iv) 
and, for Medicare payment purposes, are generally defined as having an average inpatient length of stay of 
greater than 25 days. 
 
Services in an LTACH must be medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need medical care. 
The services must be able to be furnished safely and effectively only on an inpatient basis. 
 
There is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is 
receiving appropriate care at the present acute care hospital. The enrollee does not require services at the 
LTACH that are not available at the acute care hospital where the enrollee 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 long term acute care hospital (LTACH) services.