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 has a relevant past medical history of a stroke occurring on 10/13/2019 with residual right-sided weakness. She had acute level rehabilitation and was admitted for SNF level care on 11/15/2019 and was transferred to long-term care on approximately 12/01/2019. Her relevant past medical history includes hypertension and hypothyroidism. She lives with her spouse and daughter in a multilevel home with 4 steps to the entrance with first-floor set up available. She had previously been able to function at a modified independent level in terms of mobility and was independent with remaining activities of daily living. As of 02/06/2020 she required moderate assistance for bed mobility and maximum assistance for transfers. She was non ambulatory. She required moderate assistance for upper and lower body bathing and dressing and moderate assistance for toileting. She had significantly impaired right upper extremity strength and had right lower greater than upper extremity spasticity. She was alert and oriented and motivated to participate with an impaired ability to follow complex commands. The member is now 4 months' status-post stroke as described above and is in a long-term care setting. The member's medical conditions appear stable. There are no wound care needs. She is in the long term care setting and does not require medical oversight of her 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. Speech therapy is indicated for treating residual cognitiveimpairments. The member is limited by the severity of her neurological deficits. She 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. The member's care can be appropriately provided through a lower level of care with periodicre-evaluation to see whether she would be able to benefit from therapy at a higher level of care.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.