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 has a history of a fall on 03/05/2020 and was seen in an Emergency Room. She sustained a left distal radius fracture. She has a history of 8 falls in the last 3 months. Her relevant past medical history includes cervical stenosis, chronic bilateral lower extremity lymphedema, chronic joint pain, and urinary incontinence secondary to neurogenic bowel and bladder. She is currently receiving home Health Care. The member lives in an independent living apartment at an assisted living facility and has previously used a rolling walker. As of 03/13/2020 she had shortness of breath with minimal exertion/agitation. She was considered an increased fall risk. There was 2+ edema of the legs and feet. Functionally, as of 03/17/2020 she needed assistance for all activities. There had been no falls since the last update. She was sleeping in a recliner. She was able to ambulate 100 feet with a platform walker with balance deficits. She refused exercises due to a fear of a flareup of arthritis in her knee. In occupational therapy she had poor standing balance. She required minimal assistance for toileting, showering, transitioning from seated to standing, and upper body dressing and moderate assistance for lower body activities of daily living. The member is status-post fall as described above with injury to the left wrist. The member's medical conditions appear stable. There are no wound care needs. There are no unaddressed medical issues. She is currently in an outpatient setting and does not require 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 ambulating greater than household distances and does not require an intensive rehabilitation therapy program. The member is limited by a fear of pain flare-up due to arthritis and has a limited prior level of function. 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.