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 to acute care on 01/15/2020 with altered mental status. A CT scan showed findings of a left basal ganglia hemorrhage. The member lives with his spouse in a ranch style residence with 4 steps to the entrance and had been independent in mobility and care. He was seen on 01/17/2020. He had poor coordination affecting his ability to follow commands and had right-sided weakness limiting his functional independence. He was receiving a modified diet. Functionally, he required maximum assistance for grooming and upper extremity dressing and was dependent for lower extremity dressing. Diagnoses included oropharyngeal dysphagia, mixed aphasia, and impaired mobility and activities of daily living. When seen for therapy on 01/18/2020 he required moderate assistance x2 when transitioning from seated to standing. He had a narrow base of support and right knee flexion with right lean. He had fair endurance. In occupational therapy he had decreased motor planning and apraxia was noted with activities of daily living. He was able to tolerate the treatment well. He was following one-step commands with increased time and with repetition. The member is status post admission with a new left basal ganglia hemorrhage and had been independent. The member has multiple complex medical conditions. He remains at risk for secondary complications of immobility after his stroke as well as complications related to his swallowing impairment. There would be an expected need to modify the member's treatment in order to maximize his capacity to benefit from rehabilitation. Physician supervision at an acute rehabilitation level of care is required. The member requires physical therapy for mobility, occupational therapy for remaining activities of daily living and adaptive equipment, and speech therapy for dysphagia, dysarthria, cognition, and communication. He requires an intensive rehabilitation therapy program as he is unable to perform essential activities of daily living including transfers without assistance of more than 1 person. His medical conditions are stable and he is participating in the rehabilitation therapies being provided. The member has therapy and medical needs that meet criteria for acute level rehabilitation and is an ideal candidate 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.