Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has 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 that 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 IRF care is found to be medically reasonable and necessary for this enrollee. Our physician reviewer found the enrollee was admitted for acute care on 01/23/2020 for an elective extensive fusion extending from T6 to the pelvis. The enrollee lives with his spouse in a two-level residence with 4 steps to the entrance and 18 interior stairs and had been able to function at a modified independent level. His postoperative course was complicated by anemia, thrombocytopenia, pulmonary embolism, urinary retention, and difficulty with pain control. As of 01/29/2020 he required minimal assistance when ambulating 20 feet with a rolling walker. He required minimal assistance x2 when performing transfers. He required minimal assistance x2 for bed mobility. He had low back pain rated at 9/10. He is weight-bearing as tolerated with a brace locked in extension for his left lower extremity when ambulating. Medications being prescribed for pain include intravenous Dilaudid and immediate release oxycodone 20 mg every 3 hours. The enrollee has multiple complex medical conditions. There would be an expected need to modify the enrollee's treatment in order to maximize his capacity to benefit from rehabilitation. He has a history of multiple small bowel obstructions and difficulty with pain control requiring high-dose opioids. He is at significant risk for further postoperative complications. He also has significant lower extremity weakness requiring a brace. Physician supervision at an acute rehabilitation level of care is required. The member requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. He requires assistance of more than 1 person for essential activities of daily living and requires 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. The member has therapy and medical needs that meet criteria for acute level rehabilitation. Care at a lower level would not effectively meet his rehabilitation needs.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 been met.Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.