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.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 rulesto 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 encephalopathy and hypotension on 03/09/2020. He underwent a prostatectomy on 03/16/2020 with course complicated by hypotension and hemorrhagic shock requiring intensive care unit. He was seen for follow-up. The member has a limited prior level of function referenced as being able to perform lateral transfers to his power wheelchair at baseline. He was seen for physical therapy on 03/24/2020. He was confused and irritable. He was incontinent of urine and the pad and sheets were saturated with bloody urine. He required constant cueing and encouragement to maintain alertness and would frequently fall back asleep initially during the session. He required minimal assistance for bed mobility with use of a gait belt. He seemed confused when sitting up. He was able to perform 3 small scoots while sitting at the edge of the bed with supervision. In occupational therapy he required minimal assistance for lower body dressing. A progress note indicates that his acute kidney injury has resolved. He has C. difficile colitis which is improving. His acute encephalopathy had resolved but he is now having more confusion. His heart rate was being controlled. He was not currently in an exacerbation of congestive heart failure. He was tolerating a regular diet.The member is status-post acute care admission 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. He does not require medical oversight of his 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. He has limited 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 debility and the severity of his comorbid medical conditions. He 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.