Rescinded 1981

SSR 76-26a: Sections 1814(a)(3), 1861(b), 1861(e), and 1862(a)(1) (42 U.S.C. 1395f(a)(3), 1395(x(b) and (e), and 1395y(a)(1))—Hospital Insurance Benefits—Reasonable and Necessary Services—Team Approach in Rehabilitation Services

20 CFR 405.310(g) and 405.310(k)

SSR 76-26a

(With the exception of the deletion of references to reevaluation, this is a reprint of SSR 74-34a(89).)

Where following a cerebrovascular accident with right hemiplegia and aphasia, claimant for hospital insurance benefits required and received as an inpatient of a rehabilitation hospital intensive rehabilitation services requiring a multi-disciplinary coordinated team approach to upgrade her ability to function as independently as possible, held, payment may be made since such services were required to be given on an inpatient hospital basis and were therefore reasonable and necessary for treatment of claimant's illness.

W, the claimant, was admitted to Hospital A on September 23, 1970, with a sudden onset of aphasia and right-sided hemiplegia, and remained there during the acute period of her illness. On October 19 she was transferred to X Rehabilitation Hospital where she remained until discharged on December 19, 1970.

At issue is whether payment may be made on W's behalf for the services furnished her by the X Rehabilitation Hospital for the period October 19, 1970, to December 19, 1970. The specific issue is whether it was medically necessary for her to receive treatment or diagnostic study as an inpatient in a hospital.

Section 1814 of the Social Security Act provides in part:

(a) Except as provided in subsection (d), payment for services furnished an individual may be made only to providers of services which are eligible therefore under section 1866 and only if—

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(3) with respect to inpatient hospital services . . . which are furnished over a period of time, a physician certifies that such services are required to be given on an inpatient basis for such individual's medical treatment, or that inpatient diagnostic study is medically required and such services are necessary for such purpose. . .

Section 1861(b) of the Act defines the term "inpatient hospital services" as the following items and services furnished to an inpatient of a hospital and by the hospital—

"(1) bed and board;

"(2) such nursing services and other related services, such use of hospital facilities, and such medical social services as are ordinarily furnished by the hospital for the care and treatment of inpatients, and such drugs, biologicals, supplies, appliances, and equipment, for use in the hospital, as are ordinarily furnished by such hospital for the care and treatment of inpatients; and

"(3) such other diagnostic or therapeutic items or services, furnished by the hospital, or by others under arrangements with them made by the hospital, as are ordinarily furnished to inpatients either by such hospital or by others under such arrangements;"

Section 1861(e) of the Act defines the term "hospital" as an institution which—

(1) is primarily engaged in providing, by or under the supervision of physicians, to inpatients (A) diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons;

Upon admission to X Hospital, the physical examination rendered an impression of cerebrovascular accident with right hemiplegia, aphasia, and hypertension. On October 22 W was examined by a member of the hospital's Department of Physical Medicine and Rehabilitation. His general findings show that she was totally aphasic with poor trunk balance and rightsided hemiplegia with right facial palsy.

Her first speech therapy evaluation was done October 23, 1970. The therapist felt prognosis for return of functional language was poor; however, she felt a trial period of therapy was warranted because of the inconsistent comprehension and the recent occurrence of the cerebrovascular accident. The claimant was scheduled for daily speech therapy and responded well to the first week of therapy. It is noted that at the time of evaluation her speech was usually limited to "yeh," but at the end of the first week, she was able to read words aloud and repeat a sentence although there were articulation errors. A marked change in alertness and general physical condition after 2 weeks of therapy suggested a need for re-evaluation. This was done November 10 and 11, and she showed improvement in auditory comprehension and increased verbalization.

The initial physical therapy evaluation shows that claimant needed much assistance in wheelchair management. She could come to a standing position in the parallel bars with assistance but required the assistance of two people to ambulate on them. Her balance in a standing position was only fair, which appeared to be related to muscle weakness rather than a real balance problem. A continued program of gait training was instituted. The physical therapy discharge summary indicates the claimant received physical therapy from October 21 to December 18, 1970, consisting of tilt table and progressing to ambulation. At the time of discharge, she ambulated up to 40 feet with the aid of a four-pronged cane and supervision. She required some assistance ascending and much assistance descending stairs. Difficulty getting out of her wheelchair persisted, but she could accomplish this with assistance.

An occupational therapy self-care evaluation was done on October 22, 1970. Her level of performance indicated almost total dependence; however, a self-care program including wheelchair transfers, eye-hand coordination, passive range of motion and active exercises where needed was instituted. Slow but steady progress was noted on November 3. In addition, the claimant expressed a desire to look better; therefore, it was decided to have her begin work on make-up application. By November 18 she could ambulate in physical therapy with the aid of a walker and moderate assistance. By December 10 she still needed assistance with dressing upper and lower extremities, but wheelchair transfers had improved. The occupational therapy discharge summary indicates the claimant had become capable in feeding herself, she required supervision in grooming and bathing, she could dress herself for the most part, and she needed supervision in wheelchair transfer.

A patient is considered to require a hospital level of inpatient care if he needs a relatively intensive rehabilitation program consisting of a multi-disciplinary coordinated team approach to upgrade his ability to function as independently as possible. A program of this scope usually includes intensive skilled rehabilitation nursing care, physical therapy, occupational therapy and, if needed, speech therapy. Upon admission, an assessment should be made of the patient's medical condition, attitude toward rehabilitation, functional limitations and prognosis. A decision should then be made whether rehabilitation is possible, what reasonable goals are, and how these goals are to be achieved. There need not be an expectation of the attainment of complete independence in the activities of daily living but there must be an expectation of an improvement that would be of a practical benefit to the patient.

It is noted that the claimant spent 26 days at the initial hospital where she was treated during the acute state of her illness due to a cerebrovascular accident which resulted in right hemiparesis and aphasia. The attending physician felt the claimant was a good candidate for rehabilitation as evidenced by his certification and recertification, and his statement dated September 20, 1971. He had the claimant transferred to the X Rehabilitation Hospital for specialized rehabilitation care. It was his opinion that the services she required could not be obtained in a skilled nursing facility. The record shows that her general condition had stabilized, but she did require intensive rehabilitative services consisting of various paramedical disciplines. Shortly after admission, a specialist in physical therapy medicine and rehabilitation did a consultation. A decision was made to place the claimant on a combined physical, occupational, and speech therapy program and re-evaluate her progress within 3 to 4 weeks. Although the record does not specifically state the goals they hoped to attain, it can be inferred that the goal was to attain a reasonable level of independence with activities of daily living.

The rehabilitation team met on November 6, December 4, and December 18, 1970. On the first two occasions, it was decided to continue therapy because satisfactory progress was noted. On November 18 and December 9, 1970, the utilization review committee recommended continued hospitalization because maximum rehabilitation had not yet been attained. The attending physician certified and recertified that hospitalization was required because he felt the claimant had good rehabilitation possibilities. On December 18, however, it was felt that maximum progress had been made. Accordingly, the claimant was discharged the following day. The opinions of the attending physician, the rehabilitation team, and the utilization review committee were that the claimant had good rehabilitation potential. In this instance, the Council is inclined to agree because there was, in fact, significant improvement which was of sufficient practical benefit to the claimant to justify treatment.

Therefore, on the basis that a concerted team effort was made by hospital medical personnel to rehabilitate the claimant, the inpatient rehabilitation hospital services were reasonable and medically necessary.

Accordingly, the Appeals Council held that payment may be made to X Rehabilitation Hospital on W's behalf under title XVIII of the Social Security Act for services rendered during the period October 19 to December 19, 1970.