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 this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the criteria for admission. 
 
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 At issue is whether acute inpatient rehabilitation is medically necessary. 
 
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. 
 
The patient is a 46-year-old female with a medical history of end stage renal failure requiring dialysis. Other 
medical history is notable for diabetes mellitus type I, seizure disorder, coronary artery disease, hypertension, 
hyperlipidemia, and hypothyroidism. She was admitted to the hospital on 1 3 2024 after a mechanical fall that 
resulted in a left sided peri-prosthetic fracture requiring hardware removal and plate fixation on 1 8 2024. The 
patient is non-weight bearing in the left lower extremity.  The patient did have an episode of being 
unresponsive on 1 7 2024 and work-up was negative for an acute neurological or cardiac issue. The patient is 
requiring pain control and had the placement of a pain catheter. The patient was discharged to acute inpatient 
rehabilitation on 1 12 2024. At baseline the patient requires some assistance with daily activities and mobility. 
She was having difficulty with ambulation prior to her fall. The patient is requiring minimal assistance for bed 
mobility and transfers as well as ambulating 24 feet with a walker. She requires supervision for wheelchair 
mobility. The patient is requiring minimal assistance for bathing and moderate assistance for toileting. She is 
requiring set up assistance for upper body dressing and maximum assistance for lower body dressing. The 
patient is continent of bowel and bladder.  
The complexity of the patients nursing medical and rehabilitation needs does require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. She was admitted to the hospital on 1 3 
2024 after a mechanical fall that resulted in a left sided peri-prosthetic fracture requiring hardware removal and 
plate fixation on 1 8 2024. The patient is non-weight bearing in the left lower extremity. Given the patients 
multiple medical conditions, need for pain control and recent fracture requiring surgery, she would benefit from 
the oversight of a rehabilitation physician as well as rehabilitation nursing. Her medical and rehabilitation 
needs do require the intensive interdisciplinary approach provided on acute inpatient rehabilitation. 
 
The patient 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. The patient is requiring minimal assistance for bed mobility and transfers as 
well as ambulating 24 feet with a walker. She requires supervision for wheelchair mobility. The patient is 
requiring minimal assistance for bathing and moderate assistance for toileting. She is requiring set up 
assistance for upper body dressing and maximum assistance for lower body dressing. The patient has had a 
decline from her 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.