Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that the enrollee fell and broke their hip and femur and has had surgery but will lose functionality without rehabilitation. The Plan denied your request. The Plan says the enrollee's records show that it is not reasonable to expect that they will be able to safely participate in, or fully benefit from, the intensity of services of an IRF. The Plan states it is not reasonable to expect that the enrollee would be able to take part in three (3) hours of therapy five (5) days a week or fifteen (15) hours of therapy a week. The Plan states the enrollee's records indicate that they are weak, dizzy, and that their therapists only were able to work with the enrollee for short periods of time. The Plan states the enrollee's rehabilitation needs are not complex and they do not need to see a rehabilitation doctor 3 times a week. The Plan states they can safely receive the services they need in other settings, for example: a skilled nursing facility or home with home health services.  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 the enrollee is stable with no acute medical illness and does not meet Centers for Medicare & Medicaid Services (CMS) coverage criteria for an IRF admission. With the enrollee's current medical stability, and no other acute medical complexity, there is no need for Physical Medicine and Rehabilitation (PM&R) physician supervision three (3) times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute rehabilitation nursing needs noted in the record. At the current functional level, the enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least five (5) days per week with multidisciplinary approach to daily therapy. The enrollee's therapy needs can be easily and safely provided in a skilled nursing facility (SNF). IRF admission is not medically necessary based on lack of medical complexity and nursing needs and high functional level. Document does not support the necessity for admission to IRF. While the enrollee may benefit from continued physical therapy (PT), and occupational therapy (OT), your rehabilitation needs can be safely provided in an alternate and low intensity setting such as in an SNF.  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 IRF admission and services.