Long-Term Acute Care (LTAC) Form

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Long-Term Acute Care (LTAC) Medical Policy New Policy Effective: 10/1/2025 Policy Number: UM160POL

Approval Date: 8/5/2025

Line(s) of Business: Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Long-term acute care (LTAC) is a recognized designation (by the Centers for Medicare and Medicaid Services) for acute care hospitals designed for extended stay patients with chronic conditions. Patients are admitted to LTAC hospitals following treatment in a traditional acute care hospital, but who no longer require intensive diagnostic procedures. The care provided is more individualized and resource-intensive than is provided in a skilled nursing facility or nursing home. LTAC hospitals provide specialized care services to manage complex medical conditions in patients with catastrophic or acute illnesses/injuries who require long-term highly skilled nursing and rehabilitation services.

 Line of Business

Commercial:
Refer to criteria under the Policy section in this medical policy.

Medicaid – BeHealthy:
Health New England follows MassHealth Guidelines for Medical Necessity Determination as outlined in 130 CMR 435.409 specifically medical necessity criteria listed on page 9.
https://www.mass.gov/regulations/130-CMR-435000-chronic-disease-and-rehabilitation-inpatient-hospital- services

Medicare:
Refer to criteria under the Policy section in this medical policy. Medicare does not have a National Coverage Determination (NCD) or a Local Coverage Determination (LCD) for Long Term Acute Care

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Policy

A. Admission to a LTAC facility may be considered medically necessary when all the following criteria are met:

1. The patient is medically stable for transfer to the LTAC facility and is no longer appropriate for care in the current setting (i.e., acute inpatient hospital); and
2. Needed services cannot be safely provided in a lower level of care setting (for example home health, SNF inpt. rehab); and
3. The member requires and receives daily direct Physician interventions; and

4. At least ONE of the following services is required: a. Ventilator Management that meets ALL the following criteria ii. Documentation of at least two weaning trials with tracheostomy in place prior to transfer; and iii. that the pulmonary or critical care physician specialist believes the patient can be weaned; and iv. Patient exhibits respiratory stability, including ALL the following: Safe and secure tracheostomy for at least 7 days, Sophisticated ventilator modes are not required, Positive end-expiratory pressure (PEEP) requirement 10cm H20 (981 Pa) or less, Adequate oxygenation (oxygen saturation 90% or greater) on FIO2 60% or less, Oxygenation stable during suctioning and repositioning; OR

   b. Complex medical needs with significant functional impairment, for example: ii. Multiple prolonged intravenous therapies, iii. Complex antibiotic regimen with no viable alternative, based on sensitivities
   iv. Monitoring of significantly medically active conditions requiring clinical assessment 6 or more times a day
   v. frequent interventions of at least 6 or more times a day (i.e., ventilator management, cardiac monitoring)
   vi. Complex wound care for multiple wounds stages 3 and above (i.e., negative pressure devices, repeated debridement, application of biologically active medications, whirlpool therapy)
   vii. The need for specialized high-tech equipment (i.e., on-site dialysis or surgical suites, and comprehensive rehabilitation such as physical therapy, occupational therapy, and speech therapy)

   B. Continued stay is concurrently reviewed by HNE and the need for continued service must clearly be documented in the medical records. Transition from a LTAC hospital to an alternate level of care may be considered medically necessary when ALL the following criteria have been met:

5. Care can be managed at a lower level of care, including wound care and the management of
   multiple medical conditions; and
6. Individual displays no signs of infections or is stable on an anti-infective program which can be
   administered in an outpatient setting; and
7. Individual is hemodynamically stable, has stable electrolytes, and does not require daily medication adjustments; and
8. Cardiovascular status is stable, and cardiac monitoring is not required; and
9. Individual does not require dialysis, or dialysis can be effectively performed in a lower level of care; and
10. Respiratory status is stable, and the individual does not require every 4 (four) hour monitoring; and

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7. If an individual is ventilator-dependent on admission, is now off the ventilator or is stable and unable to be weaned; and
8. The individual is stable on adequate nutrition; and

9. Pain management is adequate and does not need frequent change in medication or dose.

   Policy Guidelines and Definitions

   References

10. Centers for Medicare and Medicaid Services (CMS). What Are Long Term Care Hospitals. CMS Product No. 11347. Issued 2019. https://www.medicare.gov/Pubs/pdf/11347-Long-Term-Care- Hospitals.pdf

11. Hall WB, Willis LE, Medvedev S, Carson SS. The implications of long-term acute care hospital transfer practices for measures of in-hospital mortality and length of stay. Am J Respir Crit Care Med. 2012 Jan 1;185(1):53-7.

12. Huang, Chienhsiu. The Long-Term Survival of Successfully Weaned Prolonged Mechanical Ventilation Patients. National Library of Medicine – National Center for Biotechnology Information. Issued 2021. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8326220/

13. Kahn JM, Werner RM, David G, et al. Effectiveness of long-term acute care hospitalization in elderly patients with chronic critical illness. Med Care. 2013 Jan;51(1):4-10.
14. Kahn JM, Barnato AE, Lave JR, et al. A Comparison of Free-Standing versus Co-Located Long- Term Acute Care Hospitals. PLoS One. 2015 Oct 6;10(10):e0139742.

15. Velazco JF, Ghamande S, Surani S. Role of long-term acute care in reducing hospital readmission. Hosp Pract (1995). 2017 Oct;45(4):175-179.

    Policy Implementation

    Approved by the Medical and Pharmacy Policy Committee

    Kate McIntosh MD MBA

    Chief Medical Officer

    Saad Usmani MD MBA

    Medical Director

    Date Update 7/2025 Initial policy date

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Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Health New England expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.