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 does not meet the requirements for approval. 
 
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 61-years old with a history of colon cancer, 
hypertension, diabetes, chronic anemia, chronic obstructive pulmonary disease, CKD, and history of venous 
blood clots in the past (including pulmonary embolism) who was admitted to the hospital April 28, 2023 and 
had surgery to reverse the enrollees ileostomy then had a second surgery May 9, 2023 to remove the enrollees cecum and revise a bowel anastomosis, treat adhesions, and remove an omental mass. There was no cancer 
found at that surgery. The enrollees nasogastric tube has been removed and the enrollee continues to receive 
total parenteral nutrition. 
 
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 he/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 long term acute care hospital (LTACH) services.