Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission isnecessary for the enrollee to regain as 
much function as possible and regain their independence. The Plan denied your request. The Plan says based on 
Medicare guidelines, the inpatient rehabilitation facility services requested do not meet the requirements for 
approval. 
 
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 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 ernollee was admitted to the 
hospital on October 10, 2023 for right leg cellulitis and required right sided transtibial amputation on 
November 1, 2023. Given the enrollees medical conditions, including end stage renal failure requiring 
dialysis, he does require the oversight of a rehabilitation physician. The enrollee does require rehabilitation 
nursing, including for wound management. His medical and rehabilitation needs do require the intensive 
interdisciplinary approach provided on acute inpatient rehabilitation and 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. Currently, the enrollee 
has functional strength and range of motion in his extremities except for below his bilateral amputations. The 
enrollee requires supervision for bed mobility, minimal assistance for transfers and mobility and minimal to 
moderate assistance with daily activities. The enrolleee is a bilateral amputee and has had a significant decline 
in function and mobility and requires the intensity of therapies provided on acute inpatient rehabilitation as 
well as assessment by prosthetics for his potential for future ambulation. Therefore, the acute inpatient 
rehabilitation 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 
acute inpatient rehabilitation facility (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.