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 IRF admission is medically necessary. 
The Plan denied your request. The Plan says that the enrollee does not meet criteria for IRF admission. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollees nursing medical and rehabilitation needs does 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted to the hospital on the intensive medical unit on October 29, 2022, for sepsis and a urinary tract 
infection with metabolic encephalopathy, gout flare, acute renal failure, and nephrolithiasis. The enrollee was 
treated with antibiotics and required hemodialysis. He was transferred to the medical surgical floor on 
November 4, 2022. A dialysis catheter was placed on November 8, 2022. He was also treated for his gout flare 
with Prednisone. The enrollee has had a significant change in his baseline medical conditions, including acute 
on chronic renal failure requiring initiation of hemodialysis. He is immunosuppressed and at high risk for 
complications given his renal transplant status. He would benefit from more frequent oversight and evaluation 
of a rehabilitation physician in the acute inpatient rehabilitation setting. His medical and rehabilitation needs 
are better suited to the intensive interdisciplinary approach provided on acute inpatient rehabilitation. 
 
The enrollee does require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in 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 enrollee requires minimal to moderate assistance with 
transfers and moderate assistance when ambulating 15 feet with a walker. He requires moderate assistance with 
dressing and total assistance with toileting. The enrollee has had a functional decline from his baseline level of 
function and would benefit from the intensity of therapies provided on acute inpatient rehabilitation. Therefore, 
the acute inpatient rehabilitation admission is 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 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.