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 this is medically necessary for the member . The 
Plan denied your request. The Plan says this 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 not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found The rules say that Medicare will pay for an IRF admission when the services are 
reasonable and medically necessary. The patient must require an intensive and coordinated interdisciplinary 
approach to providing rehabilitation. The patient must need active and ongoing treatment by more than one 
therapy discipline. One of the therapies must be physical therapy or occupational therapy. The patient must 
need and be expected to actively participate in and to benefit from an intensive rehabilitation therapy program. 
This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at 
least five days per week. The patient does not need to be expected to achieve complete independence in self-
care nor be expected to return to his or her prior level of functioning. The patient must need supervision by a 
rehabilitation physician. The physician must see the patient at least three days per week throughout the stay. 
 
At the time of the request for an IRF admission, the member is stable for transfer to either skilled nursing 
facility or IRF. She has participated in therapies and as of October 23, 2023  requires moderate assistance for 
bed mobility, contact guardassistance for ambulation of 159 feet, and supervision or transfers. The patient does 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program? Note: if the patient does not require at least 3 hours a day /5 days a 
week, or 15 hours over 7 consecutive days, of therapy services but there other indicators that this patient 
requires and can participate in a rehabilitation therapy program sufficient for this level of care, please provide 
particulars as to the indicators of intensity.. 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.