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 meets medical necessity defined by 
Medicare guidelines for continued stay at the IRF. The Plan denied your request. The Plan says a medical need 
to keep staying in an acute rehabilitation facility for all days after November 11, 2023 has not been shown at 
this time.  
 
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 complexity of the enrollees nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
sustained thoracic and lumbar spine fractures after a fall. The enrollee was admitted to acute inpatient 
rehabilitation on October 28, 2023. The enrollee did not require surgical intervention for their fractures. The 
enrollee's pain is being controlled with oral medications. The enrollee is noted to have fluctuation in their 
kidney function, but this by itself does not necessitate an ongoing acute inpatient rehabilitation admission and 
the oversight of a rehabilitation physician. The enrollee does not require rehabilitation nursing for complex 
wound care, parenteral nutrition or tube feedings, tracheostomy management or neurogenic bowel and bladder 
management. The enrollee's medical and rehabilitation needs do not require the intensive interdisciplinary 
approach provided on acute inpatient rehabilitation. 
 
The patient does not 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. The patient currently requires contact guard assistance with transfers and 
ambulating with a walker and negotiating stairs. He is modified independent to requiring supervision with daily 
activities, including toileting, bathing, and dressing. The patient was modified independent with daily activities 
and mobility prior to his hospitalization. The patient has had a decline from his baseline level of function and 
may benefit from occupational and physical therapies as well as supervision and assistance, but he does not 
require the intensity of therapies provided on acute inpatient rehabilitation. 
 
Therefore, the continued acute inpatient rehabilitation admission is not 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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.