Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve IRF services through April 13, 2022. We decided that the Plan 
does not have to pre-approve IRF services beginning April 14, 2022.  
 
You asked the Plan to pre-approve IRF services through April 13, 2022. You say that you would like 
reconsideration because the continued IRF care is medically necessary. The Plan says that the enrollee does not 
meet criteria for the continued IRF care.  
We decided that the Plan has to pre-approve IRF services through April 13, 2022.  
 
The Plan follows Medicare rules. Medicare rules say that Medicare will pay for an inpatient rehabilitation 
facility (IRF) admission when the services are reasonable and medically necessary. 
 
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 services beyond April 10, 2022. 
Our physician reviewer found the enrollee lived alone, and family training was essential which was completed 
on April 13, 2022. IRF care through April 13, 2022, is medically reasonable and 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 services until April 13, 2022, have been met. Therefore, we decided that 
the Plan has to pre-approve IRF services through April 13, 2022.  
 
We also decided that the Plan does not have to pre-approve IRF services beginning April 14, 2022. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare will pay for an inpatient rehabilitation 
facility (IRF) admission when the services are reasonable and medically necessary. 
 
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 services beginning April 14, 2022. 
Our reviewer says that the enrollee with recent stroke with right sided weakness and numbness, does not meet 
the coverage criteria for an IRF stay after April 13, 2022. The enrollee is medically stable and did not need 
Physical Medicine and Rehabilitation physician close supervision 3 times per week (at a minimum) for the 
ongoing management of any active or acute exacerbations of chronic medical conditions. No rehab nursing 
needs identified or documented in the record. At the functional level described in the Physical and 
Occupational Therapy notes, the enrollee did not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. IRF 
admission beyond April 13, 2022 was not medically necessary based on medical stability and lack of medical 
complexity, lack of rehab nursing needs and high functional level. Document does not support the necessity for 
admission to an IRF beyond April 13, 2022.  
 
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 services beginning April 14, 2022 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve IRF services beginning April 14, 2022. 
 
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.