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 02/13/2020 for gastrointestinal bleeding. She had recently been admitted approximately one month before for similar symptoms. Her relevant past medical history includes chronic obstructive pulmonary disease with oxygen dependence, hypertension, anemia, a brain aneurysm, stroke, and osteoporosis. She has a normal body mass index. She was found to have multiple arteriovenous malformations (AVMs) in the distal bowel which could not be reached endoscopically. She underwent a small bowel resection on 02/20/2020. She had hypotension during the procedure. As of 02/23/2020 she was on a clear liquid diet and receiving intravenous fluids. The member had previously lived alone in a two-level residence without steps to the entrance and had been staying on the first floor. She had been independent. On 02/24/2020 she was tolerating her diet without nausea or vomiting and reported having had a bowel movement. Physical examination findings included appropriate abdominal tenderness. Her incision was intact with staples without erythema or drainage. Her abdomen was soft and nondistended. She was seen for physical and occupational therapy on 02/24/2020. She required up to minimum assistance when transitioning from supine to seated and to standing. She was able to ambulate 100 feet with a rolling walker and contact-guard assistance. The member is status-post acute care admission as described above and underwent a small bowel resection. She is tolerating a regular diet and has had a bowel movement. The member's medical conditions appear stable. There are no complex wound care needs.There are no unaddressed medical issues. 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 ambulating greater than household distances without hands-on assistance and does not require an intensive rehabilitation therapy program. The member's medical conditions appear stable and she is participating in the treatments being provided. She would be expected to be able to fully participate and 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-approveacute inpatient rehabilitation facility (IRF) admission and services