Effective Date: This policy will apply to all services performed on or after the above effective date.

Inpatient rehabilitation requires prior authorization.  Most plans have a limited benefit; refer to your benefit summary for specifics.

Inpatient rehabilitation hospitals/units are licensed and certified facilities, which primarily promote special rehabilitative health care services rather than general medical and surgical services.  Rehabilitation is defined as restoration of a disabled person to self-sufficiency or maximal possible functional independence.  An inpatient rehabilitation program utilizes an inter-disciplinary coordinated team approach that involves a minimum of three (3) hours rehabilitation services daily.  These services may include physical therapy, occupational therapy, speech therapy, cognitive therapy, respiratory therapy, psychology services, prosthetic/orthotic services, or a combination thereof. 

Inpatient rehabilitation may be provided in a hospital, a free-standing facility or skilled nursing facility. The setting for inpatient rehabilitation is principally determined by the individual`s medical and functional status. Acute inpatient rehabilitation is required when an individual`s medical status is such that the intensity of services required could not reasonably be provided in an alternative setting (subacute facility or outpatient rehabilitation department).

Acute inpatient rehabilitation services may be considered medically necessary when all of the following are present:

1. Individual has a new (acute) medical condition or an acute exacerbation of a chronic condition that has resulted in a significant decrease in functional ability such that they cannot adequately recover in a less intensive setting; AND
2. Individual`s overall medical condition and medical needs either identify a risk for medical instability or a requirement for physician and other personnel involvement generally not available outside the hospital inpatient setting; AND
3. Individual requires an intensive inter-disciplinary, coordinated rehabilitation program (as defined in the description of service) with a minimum of three (3) hours active participation daily; AND
4. Individual is medically stable enough to no longer require the services of a medical/surgical inpatient setting; AND
5. The individual is capable of actively participating in a rehabilitation program, as evidenced by a mental status demonstrating responsiveness to verbal, visual, and/or tactile stimuli and ability to follow simple commands; AND
6. Individual`s mental and physical condition prior to the illness or injury indicates there is significant potential for improvement; (See Note below) AND
7. Individual is expected to show measurable functional improvement using a recognized assessment tool (see Background) within a maximum of seven (7) to fourteen (14) days (depending on the underlying diagnosis/medical condition) of admission to the inpatient rehabilitation program; AND
8. The necessary rehabilitation services will be prescribed by a physician, and require close medical supervision and skilled nursing care with the 24-hour availability of a nurse and physician who are skilled in the area of rehabilitation medicine; AND
9. Therapy includes discharge plan.

Note:  It is not necessary that there is an expectation of complete independence in the activities of daily living; but there should be a reasonable expectation of improvement that is of practical value to the individual, measured against his condition at the start of the rehabilitation program. Additionally, the individual must have no lasting or major treatment impediment that prevents progress. (For example severe dementia)

Specific Conditions:

1.  Central Nervous System Insult

a)    Cerebrovascular accident:
Acute inpatient rehabilitation may be considered medically necessary for individuals who have suffered a cerebrovascular accident (stroke) that results in a significant impairment (contracture, paralysis, severe ataxia or paresis) in at least two extremities or at least one extremity in addition to higher central nervous system functions, including both mentation and autonomic nervous functions such as speech, swallowing and control of secretions.

b)    Acquired brain injury:
Acute inpatient rehabilitation may be considered medically necessary for individuals who have suffered an acquired brain injury (including surgical injury) that results in a significant impairment (contracture, paralysis, severe ataxia or paresis) in at least two extremities or at least one extremity in addition to higher central nervous system functions, including both mentation and autonomic nervous functions such as speech, swallowing and control of secretions.

c)     Spinal cord injury:
Acute inpatient rehabilitation may be considered medically necessary if a spinal cord injury leads to a significant impairment (contracture, paralysis or severe paresis) of at least two extremities.

Length of Stay:

This is variable and generally related to the severity of the original injury and the duration of coma or loss of consciousness.  Those with longer periods of coma will generally recover more slowly.  This is also applicable to CNS injury related to non-traumatic intracranial insults (stroke, intracranial hemorrhage, metabolic insult). 

Length of stay for spinal cord injuries is related to the level of the injury.  Injuries occurring higher in the spinal cord result in more profound loss of function and generally require longer periods of rehabilitation for adaptation.

Routine (typically weekly) reviews are completed to assess how the individual is progressing and to determine the expected length of time inpatient rehabilitation will be required.

2. Neurological disorders (Peripheral Nerve Injury, Multiple Sclerosis, Nerve Root Injury and Postoperative Deficits)

a)  Peripheral nerve injury:

Acute inpatient rehabilitation may be considered medically necessary for individuals with focal neurologic disorders which involve the peripheral nerves provided there are multiple injuries that result in a significant impairment (contracture, paralysis, or severe paresis) in at least two extremities.

Acute inpatient rehabilitation may be considered medically necessary for individuals with diffuse peripheral nervous system disorders (e.g., Guillain-Barré), which involve at least two extremities and result in significant impairment (contracture, paralysis, or severe paresis) AND the weakness is not limited to a qualitative difference since a prior inpatient admission.

b) Multiple Sclerosis:

Acute inpatient rehabilitation may be considered medically necessary for individuals with central nervous system disorders (e.g. multiple sclerosis) that result in generalized weakness provided:

·        There has been a significant decline in the individual`s functional status; AND

·        The functional decline is such that it will not self correct without treatment; AND

·        Treatment will improve functional status; AND

·        Compensatory training is needed in addition to physical therapy.  

c) Nerve root injury:

Acute inpatient rehabilitation may be considered medically necessary following nerve root injury when the individual experiences a persistent significant impairment (contracture, paralysis, or severe paresis) in at least two extremities and the deficit is not expected to be self-limited after surgical intervention (e.g. decompression).

d) Postoperative deficits:

Acute inpatient rehabilitation may be considered medically necessary for individuals recovering from neurosurgical procedures provided there are neurological deficits following the surgery and there is significant impairment such that it involves at least one extremity in addition to higher central nervous system functions.

Length of Stay:

This is variable and generally related to the severity of the original injury or surgical procedure.  Progress may be slower in members of the geriatric population as well as in individuals with co-morbidities, complications, or decreased cognitive status.

Routine (typically weekly) reviews are completed to assess how the individual is progressing and to determine the expected length of time inpatient rehabilitation will be required.

3.  Musculoskeletal/Orthopedic Disorders (Major Joint Replacement, Amputations, Major/Multiple Trauma, and Other Conditions)

a) Major joint replacements:

If a single joint is replaced, typically postoperative acute inpatient rehabilitation is considered not medically necessary unless the individual has significant comorbidity (ies) resulting in functional deficits which would necessitate an inpatient level of rehabilitation in order to achieve a satisfactory outcome within a reasonable time period. Of note, acute postoperative inpatient rehabilitation may be medically necessary for individuals undergoing more than one major joint replacement during a single hospitalization.

b) Back surgery and compression fractures:

Acute inpatient rehabilitation is considered not medically necessary for the following:

·        Uncomplicated back surgery without other concomitant diseases;

·        Uncomplicated compression fractures without neurologic involvement.

c) Amputations:

Acute inpatient rehabilitation may be considered medically necessary for individuals who have experienced the loss of more than one body part (with the exception of digits).

Rehabilitation after a single foot or leg amputation may occur in an acute inpatient or less intensive outpatient setting.  This determination is dependent upon: (1) the individual`s ability to actively participate in an intensive rehabilitation program; (2) the functional deficit caused by the amputation itself; and (3) the individual`s underlying medical condition.

Acute inpatient rehabilitation is considered not medically necessary for individuals who have suffered the loss of fingers, toes or a single hand because they do not require the intensive level of constant care provided in the inpatient setting.  These individuals typically undergo rehabilitation in a less intensive, outpatient setting.

d)    Major/multiple trauma:

Acute inpatient rehabilitation may be considered medically necessary for individuals who have:

·        Suffered massive injuries to a single extremity, OR

·        Experienced functional impairments of more than one extremity; OR

·        Experienced functional impairment such that it involves at least one extremity in addition to higher central nervous system functions.

e)    Arthritis and lupus erythematosus:

Acute inpatient rehabilitation may be considered medically necessary for individuals with severe arthritis (e.g., rheumatoid arthritis, osteoarthritis, polyarthritis, and lupus erythematosus) provided joint pathology involvement has progressed to the extent that the individual has experienced a significant functional decline in range of motion in the joint or related contractures in at least two extremities

f)      Other conditions:

Acute inpatient rehabilitation is considered not medically necessary for individuals with the following musculoskeletal/orthopedic disorders because they do not require the intensive level of constant care provided in the inpatient setting.  These individuals typically undergo rehabilitation in a less intensive, outpatient setting.

·        Simple fractures;

·        Single extremity deficits;

·        Simple (minor) trauma;

·        Generalized weakness or general debility.

Length of Stay:

This is variable and generally related to the severity of the original injury or surgical procedure.  Progress may be slower in members of the geriatric population as well as in individuals with co-morbidities, complications, or decreased cognitive status.

Routine (typically weekly) reviews are completed to assess how the individual is progressing and to determine the expected length of time inpatient rehabilitation will be required.

1)    When a member’s condition improves such that required therapy can be provided in a less intensive setting, inpatient rehabilitation will no longer be covered.

2)    If a member declines to the point that s/he is unable to participate in the minimum required three hours of daily therapy, inpatient rehabilitation will no longer be covered.