Purpose 

This medical policy outlines Highmark Health Options services for long-term acute care hospitals (LTAC).

Definitions

Highmark Health Options (HHO) – Managed care organization serving vulnerable populations that have complex needs and qualify for Medicaid. Highmark Health Options members include individuals and families with low income, expecting mothers, children, and people with disabilities. Members pay nothing to very little for their health coverage. Highmark Health Options currently services Delaware Medicaid: Diamond State Health Plan (DSHP), Delaware Healthy Children Program (DHCP), and Diamond State Health Plan Plus (DSHP) LTSS members.

Long-Term Acute Care (LTAC) – facilities that provide medical and rehabilitative care to patients with clinically complex care problems (e.g., multiple acute or chronic conditions) that require hospital-level care for an extended period of time – usually 20 to 30 days.  

Prior Authorization

Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool https://www.highmarkhealthoptions.com/providers/prior-auth-lookup

Prior authorization is required.

Procedures

Admission to an LTAC hospital may be considered medically necessary when ALL of the following criteria are met:

·         Patient has medical or respiratory complexity that requires daily physician intervention and intensive treatment; AND

·         The complexity of the patient’s condition and care needs requires placement in a Skilled Nursing Facility (SNF) or there are multiple SNF denials; AND

·         Availability of multidisciplinary team, including physical therapy (PT), occupational therapy (OT), speech therapy (ST), and/or respiratory therapy (RT); AND

·         The patient requires an RN on duty 24 hours per day.

Conditions/services that may be considered medically necessary for LTAC level of care may include, but are not limited to, ANY of the following:

·         Complex wound care:

o    Daily physician monitoring of wound

o    Wound requiring frequent complicated dressing charges, and possible repeated debridement of necrotic tissue

o    Large wound with possible delayed closure, draining, and/or tunneling or high output fistulas

o    Lower extremity would with severe ischemia

o    Skin flaps and grafts requiring frequent monitoring

·         Infectious disease:

o    Intravenous anti-infective agent(s) with adjustments in dose

o    Intensive sepsis management

o    Common conditions include osteomyelitis, cellulitis, bacteremia, endocarditis, peritonitis, meningitis/encephalitis, abscess and wound infections

·         Medical complexity:

o    Primary condition and at least two (2) other actively treated conditions that require monitoring and treatment

o    Common conditions include metabolic disorders, stroke, heart failure, renal insufficiency, necrotizing pancreatitis, emphysema (COPD), peripheral vascular disease, and              malignant/end-stage disease

·         Rehabilitation:

o    Care needs cannot be met in a rehabilitation or SNF

o    Patient has a comorbidity requiring acute care

o    Patient is able to participate in a goal-oriented rehabilitation plan of care

o    Common conditions include conditions with functional limitations, debilitation, amputation, cardiac disease, orthopedic surgery

·         Mechanical ventilator support:

o    Failed weaning attempts at an acute care facility

o    Patient has received mechanical ventilation with failed weaning attempts

o    Ventilator management required at least every 4 hours as well as appropriate diagnostic services and assessments

o    Patient exhibits weaning potential, without untreatable and/or progressive lung and/or neurological conditions

o    Respiratory status is stable with maximum positive end-expiratory pressure (PEEP) requirement 10 cm H2O and FiO2 60% or less

o    Common conditions include complications of acute lung injury, disorders of the central nervous and neuromuscular systems, and cardiovascular, respiratory, and          pleural/chest wall disorders

Transition from a LTAC hospital to an alternate level of care may be considered medically necessary when ALL of the following criteria have been met:

·         Care can be managed at a lower level of care, including wound care and the management of multiple medical conditions; AND

·         Patient displays no signs of infections or is stable on an anti-infective program which can be administered in an outpatient setting; AND

·         Patient is hemodynamically stable, has stable electrolytes, and does not require daily medication adjustments; AND

·         Cardiovascular status is stable, and cardiac monitoring is not required; AND

·         Patient does not require dialysis, or dialysis can be effectively performed in a lower level of care; AND

·         Respiratory status is stable, and the patient does not require every 4 (four) hour monitoring; AND

·         If patient is ventilator-dependent on admission, the patient is now off the ventilator or is stable and unable to be weaned and ALL of the following criteria are met:

o    Ventilator settings and airway are stable; AND

o    Stable oxygenation during movement or suctioning; AND

o    Oxygenation is adequate, e.g., SaO2 at least 90% on FiO2 40% or less; AND

o    Suction is required less often than every four (4) hours; AND

·         Patient is stable on adequate nutritional; AND

·         Pain management is adequate and does not need frequent change in medication or dose; AND

·         Neurological status is stable with mentation at baseline.

REIMBURSEMENT

Participating facilities will be reimbursed per their Highmark Health Options contract