Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say that in order for IRF care to be considered reasonable and necessary, the documentation in the patient's IRF medical record (which must include the preadmissionscreening described in section 110.1.1, the post-admission physician evaluation described in section 110.1.2,the overall plan of care described in section 110.1.3, and the admission orders described in section 110.1.4) must demonstrate a reasonable expectation that the following criteria were met at the time of admissionto the IRF:1) The patient must require the active and ongoing therapeutic intervention of multiple therapy disciplines (physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics), one of which must be physical or occupational therapy. 2) The patient must generally require an intensive rehabilitation therapy program, as defined in section 110.2.2. Under current industry standards, this intensive rehabilitation therapy program generally consists of at least 3 hours of therapy per day at least 5 days per week. Incertain well-documented cases, this intensive rehabilitation therapy program might instead consist of at least 15 hours of intensive rehabilitation therapy within a 7 consecutive day period, beginning with the date of admission to the IRF.3) The patientmust reasonably be expected to actively participate in, and benefit significantly from, the intensive rehabilitation therapy program that is defined insection 110.2.2 at the time of admission to the IRF. The patient can only be expected to benefit significantly from the intensive rehabilitation therapy program if the patient's condition and functional status are such that the patient can reasonably be expected to make measurable improvement (that will be of practical value to improve the patient's functional capacity or adaptation to impairments) as a result of the rehabilitation treatment, as defined in section 110.3, and if such improvement can be expected to be made within a prescribed period of time. The patient need not be expected to achieve completeindependence in the domain of self-care nor be expected to return to his or her prior level of functioning in order to meet this standard.4) The patientmust require physician supervision by a rehabilitation physician, defined as a licensed physician with specialized training and experience in inpatient rehabilitation. The requirement for medical supervision means that the rehabilitation physician must conduct face-to-face visits with the patient at least 3 days per week throughout the patient's stay in the IRF to assess the patient both medically and functionally, as well as to modify the course of treatment as needed to maximize the patient's capacity tobenefit from the rehabilitation process.5) The patient must require an intensive and coordinated interdisciplinary approach to providing rehabilitation, as defined in section 110.2.5You can find this information in the  Medicare Benefit Policy Manual Chapter 1, Inpatient Hospital Services Covered Under Part A. 110.2 -Inpatient Rehabilitation Facility(IRF) Medical Necessity Criteria (Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14).