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 has a relevant past medical history that includes heart failure, atrial fibrillation, pacemaker placement, hypertension, Type II diabetes with neuropathy, and an aortic valve replacement who was admitted with dyspnea and found to have acute diastolic congestive heart failure requiring intravenous diuresis. During his hospitalization he was found to have metastatic melanoma. The member is overweight with a body mass index of nearly 30. The member lives in a two-level residence with first-floor access and ramp with DME including an electric scooter, lift recliner, rollator, and wheelchair. He had previously needed assistance with activities of daily living and functional transfers. As of 02/20/2020 he required moderate assistance for bed mobility and was being transferred with a mechanical lift. He required supervision for feeding and grooming and upper body activities of daily living and was dependent for lower body activities of daily living. He required moderate assistance for bathing and maximum assistance for toileting. The member is status-post acute care admission as described above with comorbid medical conditions and recent diagnosis of metastatic melanoma. 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 unable to perform essential activities of daily living such as bed mobility or transfers. 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-approve acute inpatient rehabilitation facility (IRF) admission and services.