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 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 admitted for an elective posterior cervical laminectomy and instrumented fusion from C1-6 for cervical myelopathy. The member lives in a multilevel residence with 4 steps to the entrance and bedroom and bathroom upstairs. He had previously been independent but had started using a rolling walker approximately one month before and had used a single-point cane for stair climbing. On of 03/09/2020 he had complaints of a stiff neck. He required minimal assistance for transfers and was ambulating 60 feet x 2 with a rolling walker. In occupational therapy he received fine motor training with the use of Theraputty. A surgery progress note indicates that his strength was improving and his incision looked good. He was able to lift both lower extremities from the bed easily. As of 03/12/2020 he required minimal assistance for bed mobility and was ambulating 80 feet x 2. The member is status-post elective cervical spine surgery as described above without reported postoperative complication as described above. There is no evidence that he has a spinal cord injury. 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 is ambulating greater than household distances and is performing essential activities of daily living with minimal assistance and does not require an intensive rehabilitation therapy program. The member's medical conditions appear stable and he is participating in the treatments being provided. He 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-approveacute inpatient rehabilitation facility (IRF) admission and services.