Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested admission to an IRF does not meet criteria. Our physician reviewer found the member was admitted for acute care with persistent hypoglycemia and poor oral intake. She was diagnosed with new onset dementia, acute renal failure, hypoglycemia, hypokalemia, new onset atrial fibrillation, acute renal failure, and acute kidney injury. The member was admitted for SNF level care on 02/29/2020. The member lives alone in a single level residence and had been independent without use of an assistive device. She received assistance for instrumental activities of daily living such as driving and shopping from her daughter. She was admitted for SNF level care. A progress note on 03/07/2020 indicates that she is alert and oriented x3. She is receiving sliding scale insulin coverage. She is continent of bowel and bladder. She is compliant with her medications. As 03/08/2020 she ambulated 200 feet with handhold/contact-guard assistance for safety. She had decreased cadence with good technique. She required a single rest break. In occupational therapy she required set up for upper body dressing and standby assistance for lower body dressing and upper and lower body bathing. The member is status-post acute care admission as described above and is receiving SNF level care. The member's medical conditions appear stable. There are no wound care needs. There are no unaddressed medical issues. She is receiving SNF level care and does not require medical oversight of her condition at an acute hospital level of care. The member requires physical therapy for mobility and endurance. She is ambulating greater than household distances and is performing essential activities of daily living without hands-on
assistance and does not require an intensive rehabilitation therapy program. The member's medical conditions appear stable and she is participating in the treatments being provided. She would be expected to be able to fully participate and benefit from the required intensity of an acute rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the member's condition differently compared with therapy provided at a less intense level. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.