Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee fully meets the criteria for an IRF stay. 
The Plan denied your request. The Plan says the Medicare guidelines for IRF admission were not met and the 
enrollee can receive the services that they need at another setting like a skilled nursing facility. 
 
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 the enrollee's nursing medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee was admitted to the hospital on December 2, 2022, for COVID-19 pneumonia, pulmonary edema, and 
a urinary tract infection. The enrollee was treated with diuretics and antibiotics. The enrollee has not had a 
significant change in her baseline medical conditions other than pneumonia and a urinary tract infection, which 
have responded to medication. Their urinary incontinence is a chronic issue. The enrollee does not require the 
intensity of rehabilitation physician oversight provided in the acute inpatient rehabilitation setting. The enrollee 
does not require rehabilitation nursing for complex wound care, parenteral nutrition or tube feedings, 
tracheostomy management or bowel management. Their medical and rehabilitation needs do not require the 
intensive interdisciplinary approach provided on acute inpatient rehabilitation. 
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program at least 3 hours a day and 5 days a week, or 15 hours 
over 7 consecutive days. As of December 8, 2022, the enrollee was transferring and performing bed mobility 
with supervision. The enrollee was ambulating 20 feet with a walker with minimal assistance. The enrollee 
required minimal assistance with their daily activities, including dressing. The enrollee was noted to fatigue 
quickly with exertion. The enrollee has had a functional decline from their baseline level of function and would 
likely benefit from physical and occupational therapies, but the enrollee does not require the intensity of 
therapies provided on acute inpatient rehabilitation and it is not clear that they can tolerate the intensity of 
therapies services provided on acute inpatient rehabilitation. 
 
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.