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 the enrollee needs physical and occupational therapy 
to begin regaining their strength, balance and ability to complete activities of daily living. You say the enrollee 
lives alone and is concerned for their safety if they do not get the proper rehabilitation. The Plan denied your 
request. The Plan says the request is not medically necessary. 
 
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. Given the enrollee's post-operative 
issues and need for a wound vacuum as well as development of a deep venous thrombosis, they would benefit 
from the oversight of a rehabilitation physician. The enrollee does require rehabilitation nursing for more 
complex wound care. The enrollee's medical and rehabilitation needs do require the intensive interdisciplinary 
approach provided on acute inpatient rehabilitation. The enrollee does require 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. As of October 31, 2023, 
the enrollee required minimal assistance with ambulation with a walker. The enrollee was performing transfers 
with minimal assistance. Occupational therapy documentation indicates that the enrollee requires significant 
assistance with daily activities, including lower body dressing, bathing, and toileting. The enrollee is partial 
weight bearing in the right lower extremity. The enrollee has had a decline from their baseline level of function 
and would benefit from the intensity of therapies provided on acute inpatient rehabilitation. 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.