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 involved in a motor 
vehicle accident on October 13, 2022, which resulted in loss of consciousness and fracture of the left hip and 
right tibia and fibula. He was found to have a dislocation of the left hip with intraperitoneal hematoma and 
pelvic hematoma and traumatic brain injury with intraparenchymal, subarachnoid and subdural hemorrhage. He 
required relocation for his left hip dislocation and Open reduction and internal fixation (ORIF) of his fractures. 
His hospital stay was complicated with acute deep vein thrombosis (DVT) of the right lower extremity, hospital 
acquired pneumonia requiring antibiotics, bladder hematoma after Foley catheter placement, total parental 
nutrition due to protein-calorie malnutrition, and acute kidney injury. The enrollee has suffered neurological 
injury with a traumatic brain injury in addition to orthopedic trauma. He also has had significant complications 
during his hospital stay that include DVT, pneumonia and malnutrition. Therefore, he would benefit from the 
intensity of rehabilitation physician oversight provided in the acute inpatient rehabilitation setting. He would 
benefit from rehabilitation nursing for wound care, monitoring of his nutritional status, and bowel and bladder 
management. 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 moderate assistance with bed mobility and 
transfers and has limited ability to ambulate due to left lower extremity weight bearing status. He requires total 
assistance with lower body dressing, moderate assistance with bathing and supervision for feeding and 
grooming and hygiene. 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.