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 the enrollee will benefit from IRF admission as it 
will optimize her level of function prior to returning home.  The enrollee requires active physician oversight to 
identify and treat any problems that may arise during the recovery period. The Plan denied your request. The 
Plan says the enrollee does require physical therapy and occupational therapy services but does not require an 
intensive inpatient rehabilitation therapy program. 
 
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 the enrollee is 64 year-old female with a past medical history of Parkinson's Disease, 
glaucoma, depression, and anxiety. The member was admitted to an acute hospital on July 28, 2022, for 
treatment of a urinary tract infection and associated weakness as the member reported she had multiple recent 
falls at home. In the hospital stay the member has been treated with IV antibiotics along with physical and 
occupational therapy resulting in improved urinary symptoms; however, the weakness is ongoing. There were 
no significant adjustments were made to the Parkinson's medications either before or after the member was 
evaluated by Neurology on August 8, 2022. The Neurology evaluation noted the member to have an increase in 
falls and weakness secondary to an acute UTI superimposed on her Parkinson's disease and that the member 
does not have a significant tremor but does have some dystonia. The Neurology final recommendation was for 
the member to remain on her current home medication regimen and that the member would be a good 
candidate for rehab to regain strength for a safe return home. The complexity of the patient's nursing, medical 
and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The patient does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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 acute inpatient rehabilitation facility (IRF) admission and services.