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 seen in an
Emergency Room on 03/16/2020 with complaints of weakness, nausea and vomiting, and decreased oral
intake. She was admitted and treated for metabolic acidosis. The member lives alone and had used a rolling
walker after a fall. As of 03/23/2020 she was not having ongoing nausea or vomiting. Her heart rate was
controlled. She was alert and oriented x3 and in no acute distress. Her assessment included deconditioning. In
physical therapy on 03/24/2020 she required supervision for transfers and ambulating 120 feet x 2 with a
Rollator. She was able to negotiate 5 steps with contact-guard assistance. She had lower extremity pain when
ascending stairs. The treatment plan included progressing her endurance, strength, and mobility.
The member is status-post acute care admission as described above without injury or new significant impairing
condition. The member's medical conditions appear stable. There are no 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 progression of her mobility at a community level and to
establish a maintenance home exercise program. An occupational therapy evaluation is indicated to assess the
need for any adaptive equipment. 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 had been able to function at a modified independent level of function and 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.