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 admitted for acute care after sustaining injuries as result of a motor vehicle collision. She was the restrained driver. She struck her chest on the steering wheel. There was no airbag deployment. A CT scan of the abdomen and pelvis showed findings of mild anterior subluxation on L4/S1, a Grade 3 splenic laceration, and an L1 endplate deformity/fracture. Her spinal fracture is not treated with a brace and no surgery is being recommended. The member lives with her spouse in a single level residence and had been independent including taking care of her 13-year-old grandson. As of 02/13/2020 her pain continued to improve. Medications included acetaminophen and tramadol as needed. She had a physical examination that was within normal limits. Functionally she was able to ambulate 100 feet x 3 with a rolling walker and minimal assistance. She required supervision for bed mobility and transfers and set up for upper and lower body dressing.The member is status-post motor vehicle collision as described above. The member's medical conditions appear stable. There are no wound care needs. She has pain being treated with oral medications. 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 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 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. If stair climbing to access her residence is an issue, this would most appropriately occur on the actual stairs in the home setting.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