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 for acute care on 03/05/2020 when he was brought in for worsening weakness. His relevant past medical history includes stroke with residual right-sided weakness and polio as a child. He had recently moved and was supposed to have moved into an assisted living facility. Two days before his foot had given out while trying to get into a shower and he fell forwards without reported injury. On the morning of admission, he had been unable to sit up in bed. There were also complains of nausea without vomiting. The member has a normal body mass index. He was found to have significant hyponatremia. The member currently lives with his sister in a single level residence. At baseline he was able to ambulate with a walker and drive. DME includes a shower chair and rolling walker. As of 03/10/2020 he required moderate assist he required contact-guard assistance for bed mobility and moderate assistance when transferring and ambulating a few steps with a gait belt. The member is status-post acute care admission as described above without new injury or significant impairing condition. 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, occupational therapy for remaining activities of daily living and adaptive equipment, and speech therapy for cognition. He is unable to perform essential activities of daily living without assistance and requires an intensive rehabilitation therapy program. The member is limited by debility and his pre-hospitalization residual deficits. 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 identified reversible condition and therefore no reasonable expectation that the member will show a measurable, practical improvement in his functional status within a reasonable period of time. 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.