Coverage Policies

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.

Frequently Used Assessment Tools:

Rancho Los Amigos Cognitive Scale

The Rancho Los Amigos Cognitive Scale is a widely accepted tool which is used to serve as a guidepost of cognitive levels from admission through discharge. The Rancho Los Amigos Cognitive Scale does not require participation from the individual but is based on the clinician`s observation of the individual`s response to environmental stimuli.  There are currently two versions of this scale; the original scale includes 8 categories, while the revised scale addresses 10 categories.  Both scales are included below for easy reference.

Los Amigos Cognitive Scale - Revised

Level I - No Response: Total Assistance

• Complete absence of observable change in behavior when presented visual, auditory, tactile, proprioceptive, vestibular or painful stimuli.

Level II - Generalized Response: Total Assistance

• Demonstrates generalized reflex response to painful stimuli.
• Responds to repeated auditory stimuli with increased or decreased activity.
• Responds to external stimuli with physiological changes generalized, gross body movement and/or not purposeful vocalization.
• Responses noted above may be same regardless of type and location of stimulation.
• Responses may be significantly delayed.

Level III - Localized Response: Total Assistance

• Demonstrates withdrawal or vocalization to painful stimuli.
• Turns toward or away from auditory stimuli.
• Blinks when strong light crosses visual field.
• Follows moving object passed within visual field.
• Responds to discomfort by pulling tubes or restraints.
• Responds inconsistently to simple commands.
• Responses directly related to type of stimulus.
• May respond to some persons (especially family and friends) but not to others.

Level IV - Confused/Agitated: Maximal Assistance

• Alert and in heightened state of activity.
• Purposeful attempts to remove restraints or tubes or crawl out of bed.
• May perform motor activities such as sitting, reaching and walking but without any apparent purpose or upon another`s request.
• Very brief and usually non-purposeful moments of sustained alternatives and divided attention.
• Absent short-term memory.
• May cry out or scream out of proportion to stimulus even after its removal.
• May exhibit aggressive or flight behavior.
• Mood may swing from euphoric to hostile with no apparent relationship to environmental events.
• Unable to cooperate with treatment efforts.
• Verbalizations are frequently incoherent and/or inappropriate to activity or environment.

Level V - Confused, Inappropriate Non-Agitated: Maximal Assistance

• Alert, not agitated but may wander randomly or with a vague intention of going home.
• May become agitated in response to external stimulation, and/or lack of environmental structure.
• Not oriented to person, place or time.
• Frequent brief periods, non-purposeful sustained attention.
• Severely impaired recent memory, with confusion of past and present in reaction to ongoing activity.
• Absent goal directed, problem solving, self-monitoring behavior.
• Often demonstrates inappropriate use of objects without external direction.
• May be able to perform previously learned tasks when structured and cues provided.
• Unable to learn new information.
• Able to respond appropriately to simple commands fairly consistently with external structures and cues.
• Responses to simple commands without external structure are random and non-purposeful in relation to command.
• Able to converse on a social, automatic level for brief periods of time when provided external structure and cues.
• Verbalizations about present events become inappropriate and confabulatory when external structure and cues are not provided.

Level VI - Confused, Appropriate: Moderate Assistance

• Inconsistently oriented to person, time and place.
• Able to attend to highly familiar tasks in non-distracting environment for 30 minutes with moderate redirection.
• Remote memory has more depth and detail than recent memory.
• Vague recognition of some staff.
• Able to use assistive memory aide with maximum assistance.
• Emerging awareness of appropriate response to self, family and basic needs.
• Moderate assist to problem solve barriers to task completion.
• Supervised for old learning (e.g. self care).
• Shows carry over for relearned familiar tasks (e.g. self care).
• Maximum assistance for new learning with little or nor carry over.
• Unaware of impairments, disabilities and safety risks.
• Consistently follows simple directions.
• Verbal expressions are appropriate in highly familiar and structured situations.

Level VII - Automatic, Appropriate: Minimal Assistance for Daily Living Skills

• Consistently oriented to person and place, within highly familiar environments. Moderate assistance for orientation to time.
• Able to attend to highly familiar tasks in a non-distraction environment for at least 30 minutes with minimal assist to complete tasks.
• Minimal supervision for new learning.
• Demonstrates carry over of new learning.
• Initiates and carries out steps to complete familiar personal and household routine but has shallow recall of what he/she has been doing.
• Able to monitor accuracy and completeness of each step in routine personal and household ADLs and modify plan with minimal assistance.
• Superficial awareness of his/her condition but unaware of specific impairments and disabilities and the limits they place on his/her ability to safely, accurately and completely carry out his/her household, community, work and leisure ADLs.
• Minimal supervision for safety in routine home and community activities.
• Unrealistic planning for the future.
• Unable to think about consequences of a decision or action.
• Overestimates abilities.
• Unaware of others` needs and feelings.
• Oppositional/uncooperative.
• Unable to recognize inappropriate social interaction behavior.

Level VIII - Purposeful, Appropriate: Stand-By Assistance

• Consistently oriented to person, place and time.
• Independently attends to and completes familiar tasks for 1 hour in distracting environments.
• Able to recall and integrate past and recent events.
• Uses assistive memory devices to recall daily schedule, "to do" lists and record critical information for later use with stand-by assistance.
• Initiates and carries out steps to complete familiar personal, household, community, work and leisure routines with stand-by assistance and can modify the plan when needed with minimal assistance.
• Requires no assistance once new tasks/activities are learned.
• Aware of and acknowledges impairments and disabilities when they interfere with task completion but requires stand-by assistance to take appropriate corrective action.
• Thinks about consequences of a decision or action with minimal assistance.
• Overestimates or underestimates abilities.
• Acknowledges others` needs and feelings and responds appropriately with minimal assistance.
• Depressed.
• Irritable.
• Low frustration tolerance/easily angered.
• Argumentative.
• Self-centered.
• Uncharacteristically dependent/independent.
• Able to recognize and acknowledge inappropriate social interaction behavior while it is occurring and takes corrective action with minimal assistance.

Level IX - Purposeful, Appropriate: Stand-By Assistance on Request

• Independently shifts back and forth between tasks and completes them accurately for at least two consecutive hours.
• Uses assistive memory devices to recall daily schedule, "to do" lists and record critical information for later use with assistance when requested.
• Initiates and carries out steps to complete familiar personal, household, work and leisure tasks independently and unfamiliar personal, household, work and leisure tasks with assistance when requested.
• Aware of and acknowledges impairments and disabilities when they interfere with task completion and takes appropriate corrective action but requires stand-by assist to anticipate a problem before it occurs and take action to avoid it.
• Able to think about consequences of decisions or actions with assistance when requested.
• Accurately estimates abilities but requires stand-by assistance to adjust to task demands.
• Acknowledges others` needs and feelings and responds appropriately with stand-by assistance.
• Depression may continue.
• May be easily irritable.
• May have low frustration tolerance.
• Able to self monitor appropriateness of social interaction with stand-by assistance.

Level X - Purposeful, Appropriate: Modified Independent

• Able to handle multiple tasks simultaneously in all environments but may require periodic breaks.
• Able to independently procure, create and maintain own assistive memory devices.
• Independently initiates and carries out steps to complete familiar and unfamiliar personal, household, community, work and leisure tasks but may require more than usual amount of time and/or compensatory strategies to complete them.
• Anticipates impact of impairments and disabilities on ability to complete daily living tasks and takes action to avoid problems before they occur but may require more than usual amount of time and/or compensatory strategies.
• Able to independently think about consequences of decisions or actions but may require more than usual amount of time and/or compensatory strategies to select the appropriate decision or action.
• Accurately estimates abilities and independently adjusts to task demands.
• Able to recognize the needs and feelings of others and automatically respond in appropriate manner.
• Periodic periods of depression may occur.
• Irritability and low frustration tolerance when sick, fatigued and/or under emotional stress.
• Social interaction behavior is consistently appropriate.

Glasgow Coma Scale (GCS)

Eye Opening Response

• Spontaneous--open with blinking at baseline 4 points
• To verbal stimuli, command, speech 3 points
• To pain only (not applied to face) 2 points
• No response 1 point

Verbal Response

• Oriented 5 points
• Confused conversation, but able to answer questions 4 points
• Inappropriate words 3 points
• Incomprehensible speech 2 points
• No response 1 point

Motor Response

• Obeys commands for movement 6 points
• Purposeful movement to painful stimulus 5 points
• Withdraws in response to pain 4 points
• Flexion in response to pain (decorticate posturing) 3 points
• Extension response in response to pain (decerebrate posturing) 2 points
• No response 1 point

Head Injury Classification:

• Severe Head Injury----GCS score of 8 or less
• Moderate Head Injury----GCS score of 9 to 12
• Mild Head Injury----GCS score of 13 to 15

Functional Independence Measurement (FIM™) Score

Disability Categories