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 you believe the enrollee's medical management and 
rehabilitation requires an inpatient stay and close physician supervision. The Plan denied your request. The 
Plan says that 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 can receive care in 
another setting such as a skilled nursing facility, outpatient setting, or home health care. 
 
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 was admitted to 
the hospital on September 8, 2022, for sepsis after presenting with syncope. The enrollee was also evaluated by 
cardiology and found to have atrial fibrillation with rapid ventricular response and well as demand myocardial 
ischemia. Given the enrollee's cardiac status and demand ischemia they would benefit from the close 
supervision of a rehabilitation physician on the acute inpatient setting, especially when they receive 
occupational and physical therapies. The enrollee's medical complexity and rehabilitation needs do require the 
intensive interdisciplinary approach provided on acute inpatient rehabilitation. 
 
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. Currently, the enrollee requires moderate to maximum assistance with bed mobility 
and transfers as well as lower body dressing. The enrollee requires maximum assistance for toileting and 
bathing. The enrollee requires supervision for grooming and feeding. The enrollee has had a significant 
functional decline from his 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 
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.