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 found to be medically reasonable and necessary for this enrollee. 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 October 23, 2022, for acute hypoxic respiratory failure, acute metabolic encephalopathy, pulmonary 
hypertension, systolic heart failure, urinary tract infection, and acute renal failure. She has had the onset of 
significant cardiac and respiratory issues that would benefit from the intensity of rehabilitation physician 
oversight provided in the acute inpatient rehabilitation setting, especially as she stresses her cardiac and 
respiratory condition with therapy. Her medical 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, in an intensive rehabilitation therapy program at least three hours a day and five days a week, or 15 
hours over seven consecutive days. As of October 31, 2022, the enrollee was ambulating 6 feet with a walker 
with minimal assistance and required minimal assistance with bed mobility and moderate assistance with 
transfers. She was dependent with bathing and toileting and required moderate assistance with upper body 
dressing. The enrollee has had a functional decline from her baseline level of function, and she would benefit 
from the intensity of therapies provided in 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.