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 Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.ThePlan 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 todetermine 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 on 03/13/2020 after falling and sustaining a left hip fracture. Two days later she underwent trochanteric fixation nailing. She is weightbearing as tolerated for the left lower extremity. The member had previously been able to ambulate short distances with a rolling walker and had used a power wheelchair for longer distances. She had required assistance for activities of daily living including transfers and ambulation. She lives in an assisted living facility. As of 03/16/2020 she required moderate assistance for bed mobility and transitioning from seated to standing and ambulating 2 steps with a rolling walker with an antalgic and unsteady gait. She required moderate assistance for bathing and maximum assistance for toileting. As of 03/23/2020 she required minimal assistance x2 for bed mobility and transfers and ambulation were not performed. She was seen for speech therapy and had a 1:1 sitter due to severe confusion and without reported difficulty swallowing. A progress note on 03/24/2020 indicates that she has intermittent left hip pain and mild confusion. She has significant deconditioning and weakness. The member is status-post hip fracture and open reduction and trochanteric fixation nailing as described above with a limited prior level of function. The member's medical conditions appear stable. There are no complex wound care needs. There are no unaddressed medical issues. She does not require medical oversight of her condition at 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. However, she has a limited prior level of function. She has limited short-term goals of being able to perform bed mobility and transfer without hands-on assistance with mobility at a wheelchair level of function and does not require an intensive rehabilitation therapy program. The member is limited by pain after her recent fall 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.