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.