SSR 73-49a: Sections 1814, 1961(e) and 1962(a) (42 U.S.C. 1395f, x and y.).—Hospital Insurance Benefits—Medical Necessity for Inpatient Services—Custodial Care
20 CFR 405.116(a), 405.310(g), 405.310(k)
A hospital beneficiary, admitted to a hospital inpatient for treatment of a stroke, remained an inpatient from August 10 through November 13, 1970. Upon admission, she had complete paralysis of right arm and leg, as well as difficulty in speaking. Evaluation was made by attending physician and a team of rehabilitation specialists. A program of treatment was established and monitored by attending physician, which included daily intensive physical, occupational and speech therapy, oral medications, and daily monitoring of blood pressure. Prescribed rehabilitation services were received by patient, who progressed to ambulating with assistance, was able to communicate verbally, and attained good degree of self-sufficiency. Held, patient had by October 13, 1970, received maximum benefit in hospital and no longer required a hospital level of rehabilitation care; therefore, payment may be made only for services provided from August 10, 1970 through October 13, 1970.
W, an 80-year old female beneficiary, suffered a stroke and was admitted to X Hospital on August 10, 1970. She was discharged from this facility on November 13, 1970. Hospital insurance benefits under Part A of title XVIII of the Social Security Act were determined payable for the period August 10, 1970 through September 8, 1970, but not thereafter on the basis that a hospital level of rehabilitation care was not required or furnished.
In requesting a review of this determination, the claimant contended that the primary purpose of the hospital stay was to receive physical, occupational, and speech therapy and that according to the "Medicare Handbook" such services are covered when furnished by a qualified hospital.
Section 1814 of the 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 therefor 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 of the Act provides in pertinent part:
(e) the term "hospital" . . . means 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;
Section 1862 of the Act provides, in part:
(a) Notwithstanding any other provisions of this title, no payment may be made under part A or part B for any expenses incurred for items or services—
(1) which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member;
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(9) Where such expenses are for custodial care;
The issue to be decided is whether payment may be made on W's behalf for the services provided by the X Hospital for the period from August 10, 1970 through November 13, 1970. Whether such payment can be made depends on whether it was medically necessary for her to receive treatment or rehabilitation services as an inpatient in a hospital.
W's admission record to X Hospital shows that she had paralysis of the right arm and leg. However, she was alert, cooperative, and had control of her bladder and bowels. The aphasia manifested itself in difficulty with word finding as well as uttering wrong words and phrases. There was a slight right facial droop. The right arm and leg had no muscle function and she was unable to stand.
After many consultations between the attending physicians and rehabilitation service doctors at the hospital, it was decided that in order for the claimant to attain the maximum amount of improvement, it would be necessary for her to have a rather prolonged period of hospitalization. She received a rehabilitation program that included physical, speech, and occupational therapy. Physical therapy included a program of active and passive exercises to the right upper and lower extremities with muscle re-education techniques. There were strengthening exercises for the left upper and lower extremities and a mat program for sitting balance, and bed activity. She was to progress to standing and ambulation in the parallel bars when she was able. Speech therapy concentrated on helping her in word finding and encouraging her to read as much as possible. Occupational therapy included a functional program for the right upper extremity to maintain range of motion and stimulate muscle function, sling suspension for the right arm to the wheelchair, and an evaluation of the claimant's progress in her activities of daily life.
The physician's orders on admission to the hospital called for laboratory tests, an electrocardiogram, a physical therapy evaluation, a general diet as tolerated, a sedative, and a pain reliever for headache. The claimant was to be up in a chair with her arm in a sling. Blood pressure was to be checked on a daily basis.
The physician's progress notes indicate that the claimant was considered a good candidate for rehabilitation. Full physical, occupational, and speech therapy programs were ordered on August 11, 1970. Speech improved significantly by August 18, but no change was noted in physical therapy, with sitting balance poor. The physician noted that he would give the claimant one more week of therapy and if there were still no progress, he would make plans for discharge. On August 27, she was showing improvement and was now walking in the parallel bars. Her mood was good and her attitude toward the therapy programs was very optimistic. On September 1, strength gains were noted in the right hip. On September 8, the improvement in speech was marked. She was speaking clear words and making good sentences. On September 16, there was further encouraging improvement in physical therapy. On September 24, there was a leveling off in physical therapy improvement and small gains in occupational therapy. Discharge was again considered by the physician. However, by September 29, the claimant again made gains by ambulating in the parallel bars. On October 3, there was improvement in movement of her arm and leg. Further improvements were noted on October 5 and October 10. On October 13, she was noted to be stabilizing in her therapies. At that time, discharge was discussed with her husband. On October 17, she had no complaints and on October 21, her status remained the same. On November 3, there was further slow improvement in ambulation.
The nurse's notes reiterate the progress record, as did reports by each of the rehabilitation therapists in his particular specialty. A hospital resident physician expressed his belief that slow but definite gains were made over the entire hospitalization period, and that as long as she continued to make improvement further hospitalization was warranted. An attending physician stated that W could not have received the intensive care necessary for recovery of her speech and paralysis had it not been for prolonged hospitalization. A member of the hospital utilization review committee believed that while W achieved plateaus several times during her stay, as long as she improved at a reasonably steady pace with home placement as an objective, her care could not be classified as custodial. However, a medical advisor, responding to an interrogatory, indicated his belief that hospitalization was primarily for convenience sake. He noted that all medications could have been self-administered and controlled at home.
In the present case, the primary reason for W's hospitalization was for rehabilitation therapy. In the opinion of the Appeals Council a patient would be deemed to require a hospital level of care if he required a relatively intense rehabilitation program which required a multidisciplinary coordinated team approach to upgrade his ability to function as independently as possible. A program such as this would usually include intense skilled rehabilitation nursing care, physical therapy, occupational therapy and speech therapy, if needed. The attending physician and the therapy specialists would consult often and note programs. An assessment would be made of the patient's medical condition, functional limitations, prognosis, attitude toward rehabilitation and existence of social problems. Reasonable goals would then be made and revised if necessary.
The Council believes that the claimant received a sufficiently intense program of rehabilitation to require hospitalization. She received physical, occupational, and speech therapy 4 to 5 hours daily. These treatments were ordered by the attending physician in consultation with qualified therapists and were overseen by him. There were periodic progress checks to determine if the therapy was of sufficient benefit to the claimant to warrant continued hospitalization. Several times discharge was discussed when progress was minimal. However, the claimant would then make significant progress and a further stay was granted.
The goal of independent ambulation was not considered realistic. Instead, the goal of walking with aid and being able to communicate and achieve a good degree of self-sufficiency was substituted. It is clear from the record that the claimant benefitted greatly by the rehabilitation therapy. However, it is also shown from the record that the claimant's improvement had reached a plateau by October 13, 1970. At that time, it was believed by the hospital staff that goals had been achieved and that any further treatment would have been accomplished at home. The attending physician consulted with the claimant's husband, and the main problem after October 13, 1970, appeared to be one of obtaining a housekeeper. Nonetheless, the claimant was kept in the hospital for another month with no significant improvement.
Accordingly, the Appeals Council held that claimant had, by October 13, 1970, received maximum benefit in the hospital and no longer required a hospital level of rehabilitation care; therefore, payment may be made for services provided W from August 10, 1070 through October 13, 1070, but not thereafter.