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 on 03/04/2020 with increased weakness and frequent urination. He had previously been treated with Ceftin for a possible pneumonia. He was admitted for metabolic encephalopathy due to urinary tract infection with antibiotic associated diarrhea. The member lives in a two-level residence with 10 steps to the entrance and main floor bedroom and bathroom and had been independent. As of 03/10/2020 he was awake and alert. He was receiving intravenous levofloxacin every 24 hours. He was doing well. He was awake and alert and up in his chair. He remained confused which was his baseline. The treatment plan included replacing potassium. Functionally, he required minimal assistance for bed mobility and moderate assistance when transitioning from seated to standing. He required moderate assistance when ambulating 60 feet x 2 with a rolling walker with 1 standing rest break. He was considered a high fall risk due to a posterior lean and stooped posture with shuffling gait pattern. The member is status-post acute care admission without new injury or significant ongoing new impairing condition as described above. His metabolic encephalopathy appears to have resolved as he has returned to his baseline level of confusion. The member's medical conditions appear stable. There are no 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 household distances with moderate assistance and does not require an intensive rehabilitation therapy program. The member is limited by debility and the severity of his comorbid medical conditions and due to his recent treatments for possible pneumonia and a urinary tract infection. 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.