Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

Note: For Arkansas State or Public School employees, services subject to pre-authorization are managed by Active Health Management, as noted in their Summary Plan Description.

For coverage information on high tech imaging (MRI, CT, PET) and nuclear medicine, administered by Evicore, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 03/01/2015 Title: Long Term Acute Care Hospitalization (LTAC)
Revision Date: Document: BI475:00
CPT Code(s): None
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

 

1.    Long term acute care (LTAC) hospitalization requires prior authorization.

2.    Long term acute care (LTAC) hospitalization is covered for intensive management of complex medical needs, when the member’s needs cannot be safely met in a less restrictive setting, such as a skilled nursing facility or an inpatient rehabilitation facility.  The medical necessity criteria below must be met.

3.    LTAC is considered to be a form of skilled nursing/rehabilitation care.  See your plan documents for limits on the number of days available.


Medical Statement

LTAC hospitalization will be covered when one of the following conditions is met:

1.    Ventilator management and weaning

a.    Member is medically stable for transfer to the LTAC facility and is no longer appropriate for care in the current setting (i.e., acute inpatient hospital) AND

b.    Documentation of at least two weaning trials prior to transfer or documentation that the pulmonary or critical care physician specialist believes the member can be weaned AND

c.    Member exhibits respiratory stability, including ALL of the following:

                                                  i.    Safe and secure tracheostomy ; AND

                                                ii.    No need for sophisticated ventilator modes; AND

                                               iii.    Positive end-expiratory pressure (PEEP) requirement 10 cm H20 (981 Pa) or less; AND

                                               iv.    Stable airway resistance and lung compliance; AND

                                                v.    Adequate oxygenation (oxygen saturation 90% or greater) on FIO2 60%or less; AND

                                               vi.    Oxygenation stable during suctioning and repositioning

d.    Discharge from the LTAC facility is appropriate when:

                                                  i.    The member is hemodynamically stable without daily medication adjustments; AND

                                                ii.    The member is stable off the ventilator or is stable on the ventilator and considered not able to be weaned; AND

                                               iii.    Is clear of infection or is stable on antibiotic regimen; AND

                                               iv.    All care can be managed at a lower level of care.

2.    Complex medical needs with significant functional impairment(s)

a.    Member is medically stable for transfer to the LTAC facility and is no longer appropriate for care in the current setting (i.e., acute inpatient hospital) AND

b.    There is medical record documentation supporting the member’s need for complex medical treatment [e.g., multiple and prolonged intravenous therapies, monitoring of significantly medically active conditions requiring clinical assessment 6 or more times a day, multiple and frequent intervention of at least 6 or more times a day, like ventilator management, cardiac monitoring, complex wound care for multiple wounds stages 3 and above (such as negative pressure devices, repeated debridement, application of biologically active medications, whirlpool therapy), the need for specialized high tech equipment like cardiac monitors, on-site dialysis, or surgical suites, and comprehensive rehabilitation (physical therapy, occupational therapy, and speech therapy)]; AND

c.    Preadmission documentation must include the expected level of improvement and anticipated length of stay necessary to achieve that level of improvement; AND

d.    The needed services cannot, as a practical matter, be safely provided in a less restrictive clinical setting.

                                                  i.    The member is hemodynamically stable without daily medication adjustments; AND

                                                ii.    The member no longer requires multiple intravenous drug therapy; AND

                                               iii.    The member no longer requires cardiac monitoring; AND

                                               iv.    The member has a stable hemoglobin and hematocrit without transfusion and stable electrolytes without daily parenteral adjustments; AND

                                                v.    The member is stable on current nutritional support (whether it is parenteral, oral, or percutaneous G/J tube); AND

                                               vi.    The member no longer requires hemodialysis or is stable for transport to and from hemodialysis; AND

                                              vii.    The member is able to participate in, but not receiving, at least 3 hours of therapy daily; AND

                                            viii.    All care including wound care can be managed at a lower level of care.


Limits

1)    Most plans limit the number of days available annually.  Please see your plan documents for these limits.


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.