Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Planto pre-approveIRF care. You say that the enrollee would have the best chance at recovery through IRF treatment.The Plandenied your request. The Plansaysa lowerlevel of care would be sufficient since he does not need intensive therapy.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 IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is a male with chronic lymphocytic leukemia, left nephrectomy, atrial fibrillation, past gastrointestinal bleed with anemia and thrombocytopenia and a prior left above-the-knee amputation who presented to the acute hospital on 06/30/2020 with right lower extremity pain and swelling. He was treated in the hospital with intravenous antibiotics for cellulitis and sepsis but ultimately required a right above-the-knee amputation. He has been working with physical and occupational therapy. He is in a wheelchair and is moderate to maximum assist for transfers and stand-by assist for activities of daily living. He is medically stable. Transfer to an acute inpatient rehabilitation facility is requested.Based on theavailable records, the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and occupational therapy services but based on the medical records provided, the patient does not require an intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. We decided that the Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Planto pre-approveIRF care. You say that the enrollee would have the best chance at recovery through IRF treatment.The Plandenied your request. The Plansaysa lowerlevel of care would be sufficient since he does not need intensive therapy.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 IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is a male with chronic lymphocytic leukemia, left nephrectomy, atrial fibrillation, past gastrointestinal bleed with anemia and thrombocytopenia and a prior left above-the-knee amputation who presented to the acute hospital on 06/30/2020 with right lower extremity pain and swelling. He was treated in the hospital with intravenous antibiotics for cellulitis and sepsis but ultimately required a right above-the-knee amputation. He has been working with physical and occupational therapy. He is in a wheelchair and is moderate to maximum assist for transfers and stand-by assist for activities of daily living. He is medically stable. Transfer to an acute inpatient rehabilitation facility is requested.Based on theavailable records, the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and occupational therapy services but based on the medical records provided, the patient does not require an intensive inpatient rehabilitation therapy program. There is concern that the patient will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility.