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 11/13/2019 after undergoing groin flap surgery. She had undergone an angiogram in July
2019 with stent placement and had a right pseudo aneurysm in the femoral artery. She had undergone multiple
groin surgeries including two with flap coverage. She was admitted with discharge from the wound and
increased pain and had been more confused. She underwent debridement on 11/15/2019. Co-morbid conditions
include hyperlipidemia, end-stage renal disease requiring hemodialysis, glaucoma, congestive heart failure,
obstructive sleep apnea, atrial fibrillation, hypertension, Type II diabetes, hypothyroidism, and anxiety. She
was transferred for specialty care on 12/16/2019. She has right hip, mid pannus, and left lower abdominal
surgical wounds. She had a wound VAC which was removed on 01/20/2020. She was seen for therapy on
02/05/2020. She required standby assistance for bed mobility and moderate assistance when transitioning from
seated to standing. She was able to ambulate 3 feet at the parallel bars. In occupational therapy she was able to
perform upper body dressing independently and lower body dressing at a modified independent level. She is
able to perform wheelchair mobility with supervision.
The member is status-post treatment for surgical wounds as described above. The member's medical conditions
appear stable. There are wound care needs that can be met at a lower level of care. She 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. She is
unable to perform transfers without assistance and is ambulating in the parallel bars and requires an intensive
rehabilitation therapy program. The member is limited by pain and debility and the severity of her comorbid
medical conditions. 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.
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.