Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary, and you 
would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that 
the enrollee does not meet the requirements for admission to an IRF. 
 
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 that 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 hospitalized 
on February 22, 2023, after undergoing a vaginal vault and rectocele repair and then experiencing cardiac 
arrest. The enrollee suffered a right temporal lobe stroke and thoracic vertebrae compression fracture due to 
CPR and required tracheostomy placement and mechanical ventilation. As of March 10, 2023, the enrollees 
tracheostomy was capped, and her swallow was cleared. The enrollee continues to have a tracheostomy and 
have oxygen desaturation with effort. Given this and her multiple comorbidities, she would benefit from the 
intensity of rehabilitation physician oversight provided in the IRF setting. Her medical and rehabilitation needs 
do require the intensive interdisciplinary approach provided in an IRF. 
 
The enrollee does 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 March 13, 2023, the enrollee required minimal assistance for transfers and 
ambulating 300 feet with a walker. The enrollee required stand-by assistance for grooming, dressing, and 
toileting. The enrollee has had a functional decline from her baseline level of function and would benefit from 
the intensity of therapies provided on acute inpatient rehabilitation. Therefore, the IRF 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 
an 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.