ACUTE INPATIENT REHABILITATION FOR CENTRAL NERVOUS SYSTEM INSULT

(Cerebrovascular Accident [CVA], Acquired Brain Injury and Spinal Cord Injury) 

The information provided in this Appendix does not supersede the criteria set forth in the clinical indications section of this document.  Candidates for acute inpatient rehabilitation must meet the criteria set forth in the clinical indications section of this document. Please refer to the clinical indications section for additional criteria.

Clinical Considerations

Regarding cerebrovascular accident
Acute inpatient rehabilitation is 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.

Regarding acquired brain injury
Acute inpatient rehabilitation is considered medically necessary for individuals who have suffered an acquired brain 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.

Regarding spinal cord injury
Acute inpatient rehabilitation is 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 - Acute Inpatient Rehabilitation Setting for Individuals with Central Nervous System Insult

This is variable and generally related to the severity of the original injury and the duration ofcoma 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.

Please refer to the appendices for additional information regarding the following:

• Appendix 4 Additional Clinical Considerations for Review
  • Motor Functional Impairment Status
  • Cognitive Status
  • Multidisciplinary Team Support
• Frequently Used Assessment Tools
  • Levels of Care (Appendix A)
  • Rancho Los Amigos Cognitive Scale (Appendix B)
  • Glasgow Coma Scale (Appendix C)
  • Functional Independence Measurement (Appendix D)
  • Disability Rating Scale (Appendix E)

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

The criteria set forth in this document are based in part on the recommendations set forth in the Centers for Medicare & Medicaid Services (CMS). LMRP #L13627- Inpatient Rehabilitation.  

ACUTE INPATIENT REHABILITATION FOR NEUROLOGICAL DISORDERS

(Peripheral Nerve Injury, Multiple Sclerosis, Nerve Root Injury and Postoperative Deficits)

The information provided in this Appendix does not supersede the criteria set forth in the clinical indications section of this document. Candidates for acute inpatient rehabilitation must meet the criteria set forth in the clinical indications section of this document. Please refer to the clinical indications section for additional criteria.

Clinical Considerations

Regarding peripheral nerve injury
Acute inpatient rehabilitation is 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 is 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.

Regarding multiple sclerosis
Acute inpatient rehabilitation is 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
• Compensatory training is needed in addition to physical therapy.  

Regarding nerve root injury
Acute inpatient rehabilitation is 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).

Regarding postoperative deficits
Acute inpatient rehabilitation is considered medically necessary for individuals recovering from neurosurgical procedures provided there are neurological deficits as a result of 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 - Acute Rehabilitation Setting for Individuals with Neurological Disorders

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.

Because the length of stay varies depending on the complexity of the individual's condition, it is not unusual that 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.

Please refer to the appendices for additional information regarding the following:

• Appendix 4 Additional Clinical Considerations for Review
  • Motor Functional Impairment Status
  • Cognitive Status
  • Multidisciplinary Team Support
• Frequently Used Assessment Tools
  • Levels of Care (Appendix A)
  • Rancho Los Amigos Cognitive Scale (Appendix B)
  • Glasgow Coma Scale (Appendix C)
  • Functional Independence Measurement (Appendix D)
  • Disability Rating Scale (Appendix E)

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

The criteria set forth in this document are based in part on the recommendations set forth in the Centers for Medicare & Medicaid Services (CMS). LMRP #L13627- Inpatient Rehabilitation.  

ACUTE INPATIENT REHABILITATION FOR MUSCULOSKELETAL/ORTHOPEDIC DISORDERS

(Major Joint Replacement, Amputations, Major/Multiple Trauma, and Other Conditions)

The information provided in this Appendix does not supersede the criteria set forth in the clinical indications section of this document. Candidates for acute inpatient rehabilitation must meet the criteria set forth in the clinical indications section of this document. Please refer to the clinical indications section for additional criteria.

Clinical Considerations

Regarding 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.

Regarding 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.

Regarding amputations
Acute inpatient rehabilitation is 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.

Regarding major/multiple trauma
Acute inpatient rehabilitation is 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.

Regarding arthritis and lupus erythematosus
Acute inpatient rehabilitation is 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.

Regarding other conditions
Acute inpatient rehabilitation is generally 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 - Acute Rehabilitation Setting for Individuals with Musculoskeletal/Orthopedic Disorders

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.

Because the length of varies depending on the complexity of the individual's condition, it is not unusual that routine (typically weekly) reviews are completed to assess how the individual is progressing and determine the expected length of time inpatient rehabilitation will be required.

Please refer to the appendices for additional information regarding the following:

• Appendix 4 Additional Clinical Considerations for Review
  • Motor Functional Impairment Status
  • Cognitive Status
  • Multidisciplinary Team Support
• Frequently Used Assessment Tools
  • Levels of Care (Appendix A)
  • Rancho Los Amigos Cognitive Scale (Appendix B)
  • Glasgow Coma Scale (Appendix C)
  • Functional Independence Measurement (Appendix D)
  • Disability Rating Scale (Appendix E)

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

The criteria set forth in this document are based in part on the recommendations set forth in the Centers for Medicare & Medicaid Services (CMS). LMRP #L13627- Inpatient Rehabilitation.  

ADDITIONAL CLINICAL CONSIDERATIONS FOR REVIEW

The information provided in this Appendix does not supersede the criteria set forth in the clinical indications section of this document.  Candidates for acute inpatient rehabilitation must meet the criteria set forth in the clinical indications section of this document. Please refer to the clinical indications section for additional criteria.

Motor Functional Impairment Status
The motor functional status of individuals in this category is characterized by:

• Requires moderate to maximum assistance of another person to perform most self-care activities (i.e. feeding, grooming, dressing, bathing); AND
• Requires moderate to maximum assistance of another person to perform mobility skills, i.e. bed activities (rolling, rise to sitting position), wheelchair locomotion and transfers; AND
• Able to tolerate three or more hours per day of therapy services within the first week on the rehabilitation unit; AND
• Able to actively participate in therapies every day, at least 5 days per week; AND
• Requires an intensive level of constant care which cannot be adequately delivered in a less intensive setting (skilled nursing facility, subacute setting, outpatient rehabilitative setting or individual's home).

Note: See Appendix D for the Functional Independence Measurement and Appendix E for the Disability Rating Scale.

Cognitive Status Required to Benefit from Inpatient Rehabilitation
The individual must be able to follow simple command (verbal or demonstrated) with reasonable consistency (e.g. 50% of the time). Individuals who have experienced a head injury, multiple traumas, cerebrovascular (CV) or central nervous system (CNS) insult may start at a lesser level but must show some potential for progressive improvement in following commands during the first 2 weeks of the rehabilitation program.

Notes:

• When the illness or injury leading to the need for rehabilitation is one affecting the central nervous system, concomitant cognitive, and physical issues may exist. Cognitive issues are routinely addressed as part of acute inpatient rehabilitation. When physical rehabilitation needs no longer exist, the cognitive issues may be addressed either as part of a formal cognitive rehabilitation program, or if there are continuing speech therapy or occupational therapy needs, with the continuation of these services. For more information on cognitive rehabilitation, please see MED.00081 Cognitive Rehabilitation.
• See Appendix B for the Rancho Los Amigos Cognitive Scale.

Multidisciplinary Team Support

The specific needs of an individual will vary, however, care frequently required for individuals and which cannot be achieved at less acute levels of care such as skilled nursing facility (SNF), subacute, home health care (HHC), or outpatient therapy setting, may include the following. Please refer to the Discussion/General Information section of this document for additional information regarding these services.

• Nursing care;
• Physical therapy;
• Occupational therapy;
• Social services;
• Psychological services
• Neuropsychological services (as required);
• Speech therapy (may or may not be required).

Please refer to the appendices for additional information regarding the following:

• Frequently Used Assessment Tools
  • Levels of Care (Appendix A)
  • Rancho Los Amigos Cognitive Scale (Appendix B)
  • Glasgow Coma Scale (Appendix C)
  • Functional Independence Measurement (Appendix D)
  • Disability Rating Scale (Appendix E)

Note:  Individuals discharged from the inpatient rehabilitation setting are frequently transferred to an environment where a lesser degree of skilled medical care is required such as to a Skilled Nursing Facility, a Custodial Care setting or home.  Please refer to the documents on Custodial Care, Skilled Nursing and Skilled Rehabilitative Services (Outpatient), Skilled Nursing Facility and Home Health for additional information.  

DETERMINATION OF LEVELS OF CARE

Rehabilitative care in an acute inpatient setting is appropriate for individuals who require a more coordinated, intensive program of multiple services than is generally found in a SNF or outpatient setting.  Individuals are likely to require an inpatient level of rehabilitation if they have one or more conditions requiring intensive and multidisciplinary rehabilitation care, or a medical complication in addition to their primary condition which requires the continuing availability of a physician to ensure safe and effective treatment.

Whether an individual is admitted to a skilled nursing facility or an inpatient rehabilitation center is principally determined by the individual's degree of disability, his/her ability to actively participate in therapy, and the intensity of the program.  This table is provided as a tool to help the user distingush acute rehabilitative care from the care provided in a skilled nursing facility. 

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.

Los Amigos Cognitive Scale - Original

1. Original Scale co-authored by Chris Hagen, Ph.D., Danese Malkmus, M.A., Patricia Durham, M.A. Communication Disorders Service, Rancho Los Amigos Hospital, 1972. Revised 11/15/74 by Danese Malkmus, M.A., and Kathryn Stenderup, O.T.R. Revised scale 1997 by Chris Hagen. Available at http://www.braininjury.com/recovery.html Accessed on July 2, 2008.

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

(Adapted from: Advanced Trauma Life Support: Course for Physicians, American College of Surgeons, 1993).

1. Department of Health and Human Services Centers for Disease Control and Prevention.  Glasgow Coma Scale. Available at http://www.bt.cdc.gov/masscasualties/gscale.asp  Accessed on July 2, 2008.
2. Teasdale G, Jennett B. Assessment and prognosis of coma after head injury. Acta Neurochir 1976; 34:45-55.
3. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. Lancet 1974; 81-84.

Functional Independence Measurement (FIM™) Score

1. Getting Started with the Uniform Data System for Medical Rehabilitation, Version 5.0. Buffalo, NY 14214: State University of New York at Buffalo; 1996.
2. Guide for the Uniform Data Set for Medical Rehabilitation (including the FIM™ instrument), Version 5.1. Buffalo, NY 14214: University at Buffalo; 1997.

Disability Categories

1. Rappaport, et al. Disability rating scale for severe head trauma patients: coma to community. Archives of Physical Medicine and Rehabilitation. 1982; 63:118-123.
2. Recovery and Rehabilitation available at http://www.braininjury.com/recovery.html Accessed on July 2, 2008.