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 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 October 29, 2022, for chest pain and was found to have a Non-ST-elevation myocardial infarction (NSTEMI) with severe coronary artery disease. He required coronary artery bypass graft (CABG) x 2 and left atrial appendage (LAA) clip placement. His post-operative course was notable for atrial fibrillation and decreased left ventricle (LV) function. Given his high risk for arrythmia after CABG and myocardial infarction and the need for a Lifevest, the enrollee would benefit from the enhanced oversight and intensity of rehabilitation physician oversight provided in the acute inpatient rehabilitation setting. He also requires close monitoring and supplement oxygen during therapies given his cardiac status. His 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. Currently the enrollee requires minimal assistance with bed mobility and transfers. He is ambulating 125 feet with a walker with minimal assistance. He requires maximal assistance with lower body dressing and minimal assistance with upper body dressing, bathing, and 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.