Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plandenied 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 has a relevant past medical history that includes hypertension, congestive heart failure, neuropathy, insulin-dependent diabetes, bilateral knee replacements, and recurrent urinary tract infections. She is also overweight with a body mass index of 30. She was seen in an Emergency Room on 02/16/2020 with weakness for 3 days. She had fallen hitting her right knee and had progressive immobility and weakness. She was treated for a urinary tract infection and acutekidney injury. There was a hypotensive episode and Neurontin was decreased due to her kidney injury and encephalopathy. She was transferred for SNF level care on 02/21/2020 and is receiving physical and occupational therapy as well as speech therapy. She fell on 02/24/2020 without reported injury. The member lives with family in a single level residence with 6 steps to the entrance. Currently she requires moderate assistance for bed mobility and when ambulating 10-15 feet with a rolling walker with complaints of bilateral knee pain from her toes to her back. She requires moderate assistance for transfers and maximum assistance for dressing. She is able to self-propel her wheelchair at a distance of approximately 30 feet. 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 currently in an SNF setting and does not require an acute hospital level of care. The member requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. She is unable to perform essential activities of daily living such as bed mobility or transfer and is ambulating less than household distances. The member is limited by debility and the severity of her comorbid medical conditions. She would not be expected to be able to fully participate in or 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-approveacute inpatient rehabilitation facility (IRF) admission and services.