Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary for the enrollee to receive 
IRF care. The Plan denied your request. The Plan says that the enrollee's current medical stability and lack of 
medical complexity, there is no need for physician supervision 3 times per week. The enrollee's current level of 
function, the enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy. The 
medical records do not support the need for an intensive rehabilitation therapy program consisting of at least 3 
hours of therapy per day at least 5 days per week. The enrollee's ongoing skilled therapy and nursing needs can 
be provided at a lower level of care such as at a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 that the complexity of the enrollee's nursing medical and rehabilitation needs does require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee would benefit from 
the intensity of rehabilitation physician oversight provided in the acute inpatient rehabilitation setting. The 
enrollee also requires rehabilitation nursing for complex wound care since they currently have a wound vacuum 
in place. 
 
The enrollee does require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program at least 3 hours a day and 5 days a week, or 15 hours 
over 7 consecutive days. Physical therapy documentation dated September 29, 2022, indicated that the enrollee 
requires contact guard assistance with bed mobility, transfers, and ambulating with a walker. The enrollee 
requires minimal assistance for dressing, toileting, and bathing. The enrollee has had a functional decline from 
their baseline level of function and would benefit from the intensity of therapies provided on acute inpatient 
rehabilitation. 
 
  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.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.