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 without IRF services the enrollee is at risk for falls, 
infection, inability to return home with family, and rehospitalization The Plan denied your request. The Plan 
says the services you are requesting do not meet the requirements for approval. 
 
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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the patients nursing medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted to the hospital on 11/3/22 for a right proximal femur fracture after a fall. He required open reduction 
and internal fixation. He also had a T2 compression fracture which required bracing. The patient was noted to 
have a urinary tract infection, confusion, and hypotension post-operatively. The patient received antibiotics for 
his urinary tract infection and his hypotension resolved. He has not had a significant change in his baseline 
medical conditions other than the fracture of his femur and does not require the intensity of rehabilitation 
physician oversight provided in the acute inpatient rehabilitation setting. He does not require rehabilitation 
nursing for complex wound care, parenteral nutrition or tube feedings, tracheostomy management or bowel and 
bladder management. His medical and rehabilitation needs do not require the intensive interdisciplinary 
approach provided on acute inpatient rehabilitation. The patient does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program at least three hours a day and five days a week, or 15 hours over seven consecutive days. Currently, 
the patient requires minimal assistance for bed mobility and moderate assistance for transfers. He was not 
ambulatory as of the initial physical therapy evaluation and weight bearing as tolerated. He is dependent with 
toileting and dressing. The patient has had a functional decline from his baseline level of function, but it is 
unlikely that he can participate in and benefit from the intensity of therapies provided on acute inpatient 
rehabilitation. Therefore, the acute inpatient rehabilitation admission is not medically necessary. 
 
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.