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-year-old enrollee who has been in 
the hospital since May 3, 2023, after being hit by a vehicle. The enrollee had a fracture of the right lower leg 
and had surgery the next day to stabilize the tibia/fibula fractures. The enrollee also had a jaw dislocation. Two days later, the enrollee was found to have bilateral pulmonary emboli. The enrollee became unresponsive and 
required mechanical ventilatory support and was found to have a large subdural hematoma. The enrollee had a 
vena cava filter placed and had surgery to drain the hematoma. The enrollee is now breathing through a 
tracheostomy tube using 10 liters of oxygen per minute. The enrollee has a feeding tube. Notes from your team 
four days ago May 30, 2023, say that awake and minimally responsive. Later in the note the enrollee was 
described as nonverbal, needing mitts on your hands. The enrollees hemoglobin has dropped over the week 
from 9.5 g/dL May 27, 2023, to 8.7 g/dL the next day. The care team says the enrollee is awaiting placement. 
 
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.