CAM 457

Inpatient Rehabilitation

Category:Therapy   Last Reviewed:June 2019
Department(s):Medical Affairs   Next Review:June 2020
Original Date:August 1995    

Description:
Inpatient Physical Rehabilitation
Inpatient physical rehabilitation is a program that consists of services and treatments dedicated to restoring maximum functional independence for individuals who have experienced deficits secondary to traumatic or non-traumatic brain injury, SCI or associated neurological deficits, multi-trauma, CVA, amputations, orthopedic surgical interventions or ventilator dependence/weaning or de-conditioning secondary to medical/surgical interventions. 

Policy:
Inpatient physical therapy must be provided by an integrated interdisciplinary team comprising physicians, neuropsychologist, rehabilitation nurses, physical therapist, occupational therapist, speech language pathologist, recreation therapist, dietitians and case managers. Individualized programs are provided to meet physical, emotional, psychological, social and cognitive needs. A systematic approach is utilized for patients to reach optimal performance and to facilitate the adjustment of the patient and family to any residual limitations. Family members are considered an essential part of the rehabilitation team.

Inpatient physical rehabilitation must meet the following admission guidelines:

  • Services must be ordered by a physician and be directly related to a written treatment plan and goal.
  • The complexity and sophistication of the therapy and the patient’s condition must require the judgment, knowledge and skill of a licensed/registered physical, occupational, speech therapist and/or neuropsychologist.
  • There must be a reasonable expectation that the services will produce measurable improvement in the patient’s condition in a reasonable and predictable time period.
  • The services must be considered specific and effective for the patient’s existing condition, and the medical records must document that the patient is making progress.

Non-admission guidelines include, but are not limited to:

  • Treatment for maintenance therapy defined as activities that preserve the patient’s present level of function and prevent regression of that function.
  • Treatment with repetitive exercises to maintain strength and endurance and/or for assisted walking for an unstable patient.
  • Treatment for range of motion and passive exercises that are not related to restoration of a specific loss of function, but are useful in maintaining range in paralyzed extremities.
  • Cases in which the patient’s physical condition and/or comprehension, judgment, memory and reasoning are adequate to safely adapt to or perform basic activities of daily living.

**All inpatient rehabilitation admissions require precertification. PT, OT and speech therapy are a covered benefit when used as part of an inpatient rehabilitation service.**

Please see specific contract verbiage for exclusion, limitations and/or maximums related to inpatient rehabilitation services.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

06/01/2019 

Annual review, no change to policy intent. 

06/01/2018 

Annual review, no change to policy intent. 

06/07/2017 

Annual review, no change to policy intent. 

05/12/2017 

Corrected review date. No other changes made. 

06/01/2016 

Annual review, no change to policy intent. 

06/03/2015 

Annual review, no changes made. 

06/11/2014

Annual review, no changes made.


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