Inpatient Rehabilitation Facilities (IRFs) [For the list of services and procedures that need preauthorization, please refer to www.mcs.pr Go to Comunicados a Proveedores, and click Cartas Circulares.] Medical Policy: MP-ME-05-09 Original Effective Date: February 18, 2009 Reviewed: January 29, 2013 Revised: This policy applies to products subscribed by the following corporations, MCS Life Insurance Company (Commercial), and MCS Advantage, Inc. (Classicare) and, provider s contract; unless specific contract limitations, exclusions or exceptions apply. Please refer to the member s benefit certification language for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply subject to the aforementioned exceptions. DESCRIPTION Inpatient rehabilitation facilities (IRFs) are licensed and certified hospitals or units specialized in comprehensive rehabilitative health care. Rehabilitation is defined as the re-establishment of a disabled person to self-capacity. Inpatient rehabilitation program offer services like physical therapy, occupational therapy, speech pathology, social or psychological services, orthotics and prosthesis services to help improve functioning of patients caused by conditions such as stroke, neurological disorders, spinal cord injury, head injury, arthritis, serious fractures and loss of limb among other conditions. (MCS) will require the following criteria, which are the same, required by the Centers of Medicare and Medicaid Services (CMS) for Inpatient Rehabilitation Facilities: 1. Close Medical Supervision by a Physician with specialized training or experience in This need should be verifiable by entries in medical record that reflect frequent and direct, and medically necessary physician involvement in the patient s care; at least every 2 or 3 days during hospital stay and is an indicator of a patient s need for services generally available in hospital setting, 2. Twenty-four hour rehabilitation nursing. The patient requires 24hr availability of a registered nurse with specialized training or experience in 3. Intense level of rehabilitation services. The general threshold is that the patient must require and receive at least three hours a day of physical and/or occupational therapy. The furnishing of services no less than five days a week satisfies the requirement for daily services. In some instances, patients who require, in-patient hospital rehabilitation services may need, on a priority basis, other skilled rehabilitative modalities such as speech-language pathology services, or prosthetic-orthotic services and their stage of recovery makes the concurrent receipt of intensive physical or occupational therapy services inappropriate. 1
4. Multi-Disciplinary Team Approach to delivery of program. Includes a physician, rehabilitation nurse, social worker and/or psychologist, and those therapist involved in the patient s care. At a minimum, a team must include a physician, rehabilitation nurse, and one therapist. 5. Coordinated program of care. Patient records must reflect evidence of a coordinated program with documentation on records of periodic team conferences held at least weekly to: a) Assess the individual progress or problems impending progress; b) Consider resolutions to such problems; and c) Reassess the validity of the rehabilitation goals initially established. The decisions made during such conferences, such as those concerning discharge planning and the need for any adjustment in goals or in the prescribed treatment program, must be recorded in the clinical record. 6. Significant Practical improvement. Hospitalization is covered in those cases where the rehabilitation team concludes that a significant practical improvement can be expected in a reasonable period of time. It is not necessary that there be an expectation of complete independence in the activities of daily living, but there must be a reasonable expectation of improvement that is of practical value to the patient, measured against the patient s condition at the start of the rehabilitation program. 7. Realistic goals. The most realistic rehabilitation goal is self-care or independence in the activities of daily living as self-sufficiency in bathing, ambulation, eating, dressing, homemaking, etc, or sufficient improvement to allow a patient to live at home with family assistance rather than in an institution. The goal of treatment is achieving the maximum level of function possible. COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate member certificate and subscriber agreement contract for applicable diagnostic imaging, DME, laboratory, medical procedures, and drug formulary coverage. 2
INDICATIONS (MCS) will consider Inpatient Rehabilitation Facility (IRF) medically necessary, when the following criteria are met at the time of admission to IRF: 1. The patient must require the active and ongoing therapeutic intervention of multiple therapy disciplines (physical therapy, occupational therapy, speech language pathology, or prosthetics/orthotics), one of which must be physical or occupational therapy. 2. The patient must generally require an intensive rehabilitation therapy program. 3. The patient must reasonably be expected to actively participate in, and benefit significantly from, the intensive rehabilitation therapy program. 4. The patient must require physician supervision by a rehabilitation physician. 5. The patient must require an intensive and coordinated interdisciplinary approach to providing Note 1 : Under current industry standards, the intensive rehabilitation therapy program generally consists of at least 3 hours of therapy per day at least 5 days per week. In certain well-documented cases, this intensive rehabilitation therapy program might instead consist of at least 15 hours of intensive rehabilitation therapy within a 7 consecutive day period, beginning with the date of admission to the IRF. Rehabilitation physician is a licensed physician with specialized training and experience in inpatient The requirement for medical supervision means, that the rehabilitation physician must conduct face to face visits with the patient at least 3 days per week, throughout the patients stay in the IRF to assess the patient both medically and functionally, as well as to modify the course of treatment as needed to maximize the patients capacity to benefit from the rehabilitation process. 3
MCS will consider the following as qualifying medical conditions for treatment in an IRF. Other clinical scenarios will be considered in a case-by-case basis. All scenarios must meet criteria under Indications section of this policy. Medical Condition Stroke Spinal cord injury Congenital deformity Major Limb Amputation Major multiple trauma Femur fracture (hip fracture) Brain injury Neurological disorders Burns Active, polyarticular rheumatoid, psoriatic arthritis, and seronegative arthropathies Systemic vasculitides with joint inflammation Severe advanced osteoarthritis Additional comments and requirements pertaining to the condition Including multiple sclerosis, motor neuron diseases, polyneuropathy, muscular dystrophy, and Parkinson s disease. Must result in significant functional impairment of ambulation and other activities of daily living that: Have not improved after an appropriate, aggressive, and sustained course of outpatient therapy services or; Services in other less intensive rehabilitation settings immediately preceding the inpatient rehabilitation admission; or Result from systemic disease activation immediately before admission, but have the potential to improve with more intensive Must result in significant functional impairment of ambulation and other activities of daily living that: Have not improved after an appropriate, aggressive, and sustained course of outpatient therapy services; or Services in other less intensive rehabilitation settings immediately preceding the inpatient rehabilitation admission; or Result from systemic disease activation immediately before admission, but have the potential to improve with more intensive Osteoarthritis or degenerative joint disease involving two or more major weight bearing joints (elbow, shoulders, hips or knees but not counting a joint with prosthesis) with joint deformity and substantial loss of range of motion, atrophy of muscles surrounding the joint. Must result in significant functional impairment of ambulation and other activities of daily living that: Have not improved after an appropriate, aggressive, and sustained 4
course of outpatient therapy services; or Services in other less intensive rehabilitation settings immediately preceding the inpatient rehabilitation admission; or Result from systemic disease activation immediately before admission, but have the potential to improve with more intensive Please note, a joint replaced by prosthesis is no longer considered to have osteoarthritis, or other arthritis, even through this condition was the reason for the joint replacement. Knee or hip joint replacement, or both, during an acute hospitalization immediately preceding the inpatient rehabilitation stay The condition must meet one or more of the following specific criteria; the patient: Underwent bilateral knee or bilateral hip joint replacement surgery during the acute hospital admission immediately preceding the IRF admission; Is extremely obese with a Body Mass Index of at least 50 at the time of admission to the IRF; Is age 85 or older at the time of the admission to the IRF REFERENCES 1. American Academy of Physical Medicine and Rehabilitation. Standards for Assessing Medical Appropriateness Criteria for Admitting Patients to Rehabilitation Hospitals or Units. Prepared by: Medical Inpatient Rehabilitation Criteria Task Force; John L. Melvin, MD, MMSc, Chairman. Accessed January 29, 2013. Available at URL address: http://www.aapmr.org/advocacy/healthpolicy/medical-necessity/pages/mirc-task-force-report.aspx 2. Centers for Medicare & Medicaid Services (CMS). Article for Inpatient Rehabilitation Care Facility (IRF) Requirements (A18651). Article Retired and Archived. Original Effective Date: 1/29/2004. Article Revision Ending Date: 7/31/2008. Accessed January 29, 2013. Available at URL address: http://coverage.cms.fu.com/mcd_archive/viewarticle.asp?article_id=18651&article_version=2& show=all 3. Centers for Medicare & Medicaid Services (CMS). Inpatient Rehabilitation Facility Federal Regulation Number CMS-1433-N. Prospective Payment System for Federal Fiscal Year 2013. Accessed January 29, 2013. Available at URL address: https://www.cms.gov/medicare/medicare-fee-for-service- Payment/InpatientRehabFacPPS/List-of-IRF-Federal-Regulations-Items/CMS-1433-N-New.html 4. Centers for Medicare & Medicaid Services (CMS). Local Coverage Article for AIRF: Inpatient Rehabilitation facilities revision to the LCD (A49650). Original Article Effective Date: 12/17/2009. Accessed January 29, 2013. Available at URL address: http://www.cms.gov/medicare-coverage-database/details/article- 5
details.aspx?articleid=49650&ver=2&contrid=196&contrver=1&cntrctrselected=196*1&search Type=Advanced&CoverageSelection=Both&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cT A%7cMCD&ArticleType=Ed%7cKey%7cSAD%7cFAQ&PolicyType=Final&s=46&CntrctrType=8&Ke yword=inpatient+rehabilitation&keywordlookup=doc&keywordsearchtype=exact&kq=true& bc=iaaaabaaaaaa& 5. Centers for Medicare & Medicaid Services (CMS) Manual System. Pub 100-02 Medicare Benefit Policy. Transmittal 119. Subject: Coverage of Inpatient Rehabilitation Services. Change Request 6699. Date: January 15, 2010.. Accessed January 29, 2013. Available at URL address: https://www.cms.gov/transmittals/downloads/r119bp.pdf 6. Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual Chapter 1, Section 110 - Inpatient Hospital Stays for Rehabilitation Care. Last revision 01/15/2010. Accessed January 29, 2013. Available at URL address: http://www.cms.gov/manuals/downloads/bp102c01.pdf 7. Centers for Medicare & Medicaid Services (CMS). Medicare Inpatient Rehabilitation Facility Classification Criteria. Last updated April 12, 2012. Accessed January 29, 2013. Available at URL address: https://www.cms.gov/inpatientrehabfacpps/03_criteria.asp#topofpage 8. Centers for Medicare & Medicaid Services (CMS). Medicare Inpatient Rehabilitation Facility Classification requirements. Medicare Learning Network (MLN) Matters Number: MM3334. Effective Date: 7/1/2004. Implementation Date: 7/1/2004. Accessed January 29, 2013. Available at URL address: https://www.cms.gov/mlnmattersarticles/downloads/mm3334.pdf 9. Centers for Medicare & Medicaid Services (CMS). Retired Local Coverage Determination (LCD) for Inpatient Rehabilitation Facilities (L28913). Original Determination Ending Date: 01/01/2010. Accessed January 29, 2013. Available at URL address: http://coverage.cms.fu.com/mcd_archive/viewlcd_pdf.asp?lcd_id=28913&lcd_version=5&contr actor_id=196 10. Centers for Medicare & Medicaid Services (CMS). U.S. Department of Health and Human Services. Medicare Learning Network: Inpatient Rehabilitation Facility Prospective Payment System. ICN 006847 / September 2012. Accessed January 29, 2013. Available at URL address: http://www.cms.gov/mlnproducts/downloads/inpatrehabpaymtfctsht09-508.pdf 11. Centers for Medicare & Medicaid Services (CMS). U.S. Department of Health and Human Services. List of IRF Federal Regulations. Regulation No. CMS-1349-P. Title of document: Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2012; Changes in Size and Square Footage of Inpatient Rehabilitation Units and Inpatient Psychiatric Units. Publication Date: April 29, 2011. Accessed January 29, 2013. Available at URL address: https://www.cms.gov/medicare/medicare-fee-for-service- Payment/InpatientRehabFacPPS/List-of-IRF-Federal-Regulations-Items/CMS1246992.html 12. U.S. Government Accountability Office. Medicare: More Specific Criteria Needed to Classify Inpatient Rehabilitation Facilities GAO-05-366. April 22, 2005. Accessed January 29, 2013. Available at URL address: http://www.gao.gov/products/gao-05-366 & http://www.gao.gov/assets/250/246084.pdf 6
POLICY HISTORY DATE ACTION COMMENT February 18, 2009 Origination of Policy April 22, 2010 Revised CMS LCD retired; information was revised using Medicare Benefit Policy Manual April 22, 2011 Yearly Review April 27, 2012 Yearly Review References updated. Under Indications: The term Only, was deleted right before the phrase: the following as qualifying medical conditions. In addition, the following was added Other clinical scenarios will be considered in a case by case basis. All scenarios must meet criteria under Indications section of this policy January 29, 2013 Yearly Review References updated. New references were added: numbers 2-4, & 9. This document is for informational purposes only. It is not an authorization, certification, explanation of benefits, or contract. Receipt of benefits is subject to satisfaction of all terms and conditions of coverage. Eligibility and benefit coverage are determined in accordance with the terms of the member s plan in effect as of the date services are rendered., (MCS) medical policies are developed with the assistance of medical professionals and are based upon a review of published and unpublished information including, but not limited to, current medical literature, guidelines published by public health and health research agencies, and community medical practices in the treatment and diagnosis of disease. Because medical practice, information, and technology are constantly changing, Medical Card System, Inc., (MCS) reserves the right to review and update its medical policies at its discretion, (MCS) medical policies are intended to serve as a resource to the plan. They are not intended to limit the plan s ability to interpret plan language as deemed appropriate. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment they choose to provide. 7