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 is with Parkinson's disease and was admitted to SNF for sepsis and degenerative lumbar disc disease with spinal stenosis requiring subacute rehabilitation from 1/9/20 to 1/14/20. The enrollee left against medical advice on 1/14/20 back to home as he felt he was getting little therapy. The enrollee was admitted to acute care on 1/20/20 for urinary tract sepsis, positive C. Difficile and enterococcus bacteremia and difficulty walking. On 1/21/20 white blood count (WBC) was 11.9, BUN was 54, and creatinine was 1.82. On 1/24/20 BUN was 42 and creatinine was 1.20. Glucose was 259. Progress note dated 1/25/20 reveals BUN was 40 and creatinine was 1.26. 1/26/20 progress notes BUN was 35, creatinine was 1.00, glucose was 181, and WBC was 10.0. On 1/27/20 BUN was 45, Creatinine was 1.2 and WBC was 12.0. 1/27/20 glucose was 203. Per a 1/28/20 progress note the enrollee was seen by neurosurgery and recommended to have intervention for severe lumbar spinal canal stenosis and degenerative spondylolisthesis but was not cleared due to active infection. He was started on decadron. The enrollee's severe sepsis resolved and he is on Ertapenem through 1/27/20. He is afebrile and WBC is stable. His C. difficile colitis is improving on oral vancomycin. He was started on SSI for hyperglycemia suspected to be worse due to steroids. His rhabdomyolysis and acute kidney injury resolved with IVF. He is to continue his home regimen for Parkinson's disease and hypothyroidism. He will follow up as outpatient for his prostate cancer status post radiation history. The complexity of the enrollee's nursing, medical and rehabilitation needs do require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does reveal that the enrollee requires the intensity of an IRF stay with close physician or nursing supervision. The most recent progress note reveals a slight increase in the enrollee's WBC count from days prior despite tapering steroids. Additionally, there has been some recent elevation again in his BUN and also creatinine. The enrollee's hyperglycemia is still not controlled adequately. These findings will require more intensive lab monitoring than in a lesser setting. The enrollee will likely benefit and participate in additional therapy of at least PT and OT which given his medical status would best occur on an intensive rehabilitation facility therapy program level in an IRF.
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.