Acute Inpatient Rehabilitation Criteria

Inpatient Rehabilitation Facility services provide multidisciplinary approach in a hospital setting to restore or enhance function after an illness or injury.  The services are appropriate for patients with complex nursing, medical management and rehabilitative needs. Determinations of whether inpatient rehabilitation facility services are reasonable and necessary must be based on an assessment of each patient’s individual care needs. The following criteria must be met at the time of admission for inpatient rehabilitation care to be considered reasonable and necessary. 

Custodial care is care that can be given by non-professional staff and is not considered skilled care.  Custodial care is not covered under your medical plan.

  1. Require active and ongoing intervention of at least 2 of the multiple therapy disciplines (Physical Therapy-PT, Occupational Therapy-OT, Speech-language Pathology-SLP, or prosthetics/orthotics), at least one of which must be physical therapy or occupational therapy.
  2. The patient must require an intensive rehabilitation therapy program.

• The program generally consists of at least 3 hours of therapy per day at leave 5 days per week

or

• In certain well-documented cases, at least 15 hour of intensive rehabilitation therapy within a 7-consecutive day period,             beginning with the date of admission to the inpatient rehabilitation facility.

  1. The patient must reasonably be expected to actively participate in, and benefit from, the intensive rehabilitation therapy program at the time of admission to the inpatient rehab facility.  The patient can only be expected to benefit significantly from the intensive rehabilitation therapy program if the patient’s condition and functional status are such that the patient can reasonably be expected to make measurable improvement (that will be of practical value to improve the patient’s functional capacity or adaptation to impairments) as a result of the rehabilitation treatment, and if such improvement can be expected to be made within a prescribed period of time.
  2. The patient must require physician supervision by a rehabilitation physician, defined as a licensed physician with specialized training and experience in inpatient rehabilitation.  The requirement for medical supervision means that the rehabilitation physician must conduct face-to-face visits with the patient at least 3 days per week throughout the patient’s stay in the inpatient rehab facility to assess the patient both medically and functionally, as well as to modify the course of treatment as needed to maximize the patient’s capacity to benefit from the rehabilitation process.  An Advanced Practice Provider (APP) may perform 1 of the 3 required visits in lieu of the physician in the second and later weeks of the patient’s care if this is permitted within the APP’s scope of practice under state law
  3. The patient must require an intensive and coordinated interdisciplinary approach to providing rehabilitation. 

Skilled staff in the Inpatient Acute Rehabilitation program include:

  • Rehabilitation Physicians
  • Rehabilitation Trained Registered Nurses
  • Physical Therapists
  • Occupational Therapists
  • Recreational Therapists
  • Speech-Language Pathologists
  • Licensed Social Workers
  • Rehabilitation Trained Mid-Level Providers

Effective: 1/1/2026