Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have an enlarged prostate and currently have a 
catheter. You say that your doctor is recommending prostate surgery, but you need rehabilitation first because 
the surgery cannot be done due to the position they need you in that can cause more damage to your hip. The 
Plan denied your request. The Plan says based on the need for intensive skilled therapy in an IPR setting, we 
did not see that Medicare criteria were met. 
 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 that the complexity of your nursing medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted to 
the hospital on April 4, 2023, for a right sided femoral fracture after falling at home. You required hip 
arthroplasty on April 5, 2023. You required a Foley catheter placed for urinary retention. You have not had a 
significant change in your baseline medical conditions other than the fracture of your hip and you do not 
require the intensity of rehabilitation physician oversight provided in the acute inpatient rehabilitation setting. 
You have not had an acute change in your neurological status. You do not require rehabilitation nursing for 
complex wound care, parenteral nutrition or tube feedings, or tracheostomy management. You require a Foley 
catheter for urinary retention, but this does not necessitate the intensity of care provided on acute inpatient 
rehabilitation. Your medical and rehabilitation needs do not require the intensive interdisciplinary approach 
provided on acute inpatient rehabilitation. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program at least three hours a 
day and five days a week, or 15 hours over seven consecutive days. You are weight bearing as tolerated in the 
right lower extremity. Currently you require minimum assistance for bed mobility and transfers. You are 
ambulating with contact guard assistance with the use of a walker and requiring moderate assistance for lower 
body dressing. You have had a decline from your baseline level of function and would likely benefit from 
therapy after your hip fracture, but this does not necessitate the intensity of therapies provided on acute 
inpatient rehabilitation. Therefore, the acute inpatient rehabilitation admission is not 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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.