CurrentIndependent HealthPolicy M20210312011

Long Term Acute Care (LTAC)

Defines Independent Health's medical necessity criteria and pre-authorization requirement for inpatient services in long-term acute care (LTAC) facilities across specified lines of business.

Policy Summary

PayerIndependent Health

PolicyLong Term Acute Care (LTAC)

Policy CodePolicy M20210312011

Change TypeReview (no material changes)

Effective Date5/1/2021

Next Review Date

Key ActionObtain pre-authorization and submit documentation for Independent Health Medical Director review demonstrating medical complexity and that care cannot be provided in a less intensive setting.

SourceLink

POLICY UPDATE CHANGES

5/1/2026 review noted; prior entries include formatting-only revision on 8/1/2025 and other review dates.

>25daverage inpatient length of stay for LTAC

YesPre-authorization required

MultipleApplicable lines of business

M20210312011Policy identifier

Coverage Criteria for LTAC Services

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Covered when ALL of the following are met

Services provided in an LTAC facility are covered upon Independent Health Medical Director review, when the individual's condition cannot be adequately treated in a less intensive setting, for ALL of the following:

LTAC coverage criteria: The individual requires acute or subacute ongoing medically necessary inpatient hospital care services; the individual is medically complex with one or more medical comorbidities (which are currently stable); care cannot be adequately treated in a less intensive setting.

Pre-authorization required; all cases reviewed by Independent Health Medical Director for medical appropriateness.

Services that can be adequately provided in a less intensive setting (for example, a skilled nursing facility, nursing home, or acute rehabilitation facility) are not appropriate for placement in a long-term acute care (LTAC) facility. LTACs provide more individualized and resource‑intensive care than these settings and are intended for clinically complex individuals whose needs exceed what a less intensive facility can safely and effectively deliver.

Admission to an LTAC is not medically necessary when the individual's condition does not require ongoing acute or subacute medically necessary inpatient hospital care, or when the member's needs can be met in a less intensive setting. Independent Health requires that cases demonstrate the need for continued inpatient-level services and medical complexity; absent those factors, LTAC placement should not be authorized.

Admission Criteria

LTAC — Admission criteria

Admission to an LTAC setting is appropriate when the following admission condition is met and pre-authorization/Medical Director review has been completed:

Admission to LTAC: Individual requires acute or subacute ongoing medically necessary inpatient hospital care; individual is medically complex with one or more currently stable comorbidities; services cannot be adequately provided in a less intensive setting; Medical Director review and pre-authorization obtained.

Applies to applicable lines of business; benefit assignment may vary by acuity.

Continued Stay Criteria

LTAC — Continued stay criteria

Continued stay in an LTAC facility is authorized when ongoing need and medical appropriateness are documented and confirmed by Medical Director review:

Continued stay considerations: Ongoing need for acute or subacute inpatient care and continued medical complexity; comorbid issues have been stabilized/addressed; continued medical appropriateness as determined by Independent Health Medical Director review.

Benefit assignment may change if acuity shifts to subacute; pre-authorization and Medical Director review required for continued stay.

Discharge Criteria

Discharge from LTAC should occur when the member no longer requires acute or subacute medically necessary inpatient hospital care or when the individual's needs can safely and effectively be met in a less intensive setting. Transfer to a lower-acuity setting is appropriate once comorbid issues have been stabilized/addressed and ongoing inpatient-level interventions are no longer required.

Coding and Utilization Metrics

Average inpatient length of stay

Average inpatient length of stay> 25 days

Setting describedLong-term acute care facility provides medical and rehabilitative care for clinically complex individuals with multiple acute or chronic conditions.

Comparison to other settingsOffers more individualized and resource-intensive care than skilled nursing facility, nursing home, or acute rehabilitation facility.

Typical services includedMay include comprehensive rehabilitation, respiratory therapy, complex wound therapy, cancer treatment, head trauma treatment, and pain management.

Provider Actions and Requirements

Prior Authorization

Pre-authorization and Medical Director review

Pre-authorization is required for LTAC placement and all cases are subject to review by an Independent Health Medical Director for medical appropriateness.

Step Therapy

Benefit determination based on acuity

Determine benefit assignment based on the member's acuity: consideration may be made when comorbid issues have been stabilized/addressed, and services may be assigned to different benefits depending on whether care needs are acute or subacute.

Documentation Required

Required clinical documentation

Document that the individual requires ongoing acute or subacute medically necessary inpatient hospital care and that the individual is medically complex with one or more currently stable comorbidities; support that care cannot be provided in a less intensive setting.

Denial Risk

Medical Director review and pre-authorization — denial risk

Services require Independent Health Medical Director review and pre-authorization; absence of pre-authorization or failure to demonstrate medical appropriateness (for example, needs that can be met in a less intensive setting or lack of medical complexity) may result in denial or non‑coverage.

Definitions

Long term acute care (LTAC) definition

DefinitionA 24-hour inpatient comprehensive program of integrated medical and rehabilitative services provided in an approved LTAC facility during the acute phase of a member's care.

Level of careInpatient, 24-hour medical and rehabilitative services for clinically complex patients.

Typical patient profileClinically complex individuals with multiple acute or chronic conditions.

Relation to length of stayLTAC facilities have an average inpatient length of stay greater than 25 days.

Background

Long-term acute care (LTAC) facilities provide 24-hour inpatient medical and rehabilitative services for clinically complex individuals with multiple acute or chronic conditions and an average inpatient length of stay of greater than 25 days. LTAC care is more resource-intensive and individualized than care in a skilled nursing facility or acute rehabilitation setting and commonly includes services such as comprehensive rehabilitation, respiratory therapy, complex wound therapy, cancer treatment, head trauma treatment, and pain management. Independent Health requires pre-authorization and Medical Director review to confirm that the member requires ongoing acute or subacute inpatient care and that those needs cannot be met in a less intensive setting; benefit assignment may change depending on whether care needs are acute or subacute.

Revision History

2026-05-01reviewLatest

Policy reviewed by Health Care Services (signature/approval on file).

2025-08-01revision

Formatting-only revision by Health Care Services.

2025-05-01review

Policy reviewed by Health Care Services.

2024-05-01review

Policy reviewed by Health Care Services.

2024-01-01revision

Policy revised by Health Care Services.

2023-05-01review

Policy reviewed by Health Care Services.

2022-05-01review

Policy reviewed by Health Care Services.

Policy Summary

PayerIndependent Health

PolicyLong Term Acute Care (LTAC)

Policy CodePolicy M20210312011

Change TypeReview (no material changes)

Effective Date5/1/2021

Next Review Date

SourceLink

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