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 it is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not meet the requirements for approval. 
 
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 enrollee is a 90-year-old with a medical history of hypertension, atrial 
fibrillation, congestive heart failure and hip pain.  
 
The complexity of the enrollees nursing medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted to the 
hospital on May 31st, 2023, after suffering a non-displaced fracture of the right inferior and superior pubic 
ramus from a fall. The enrollee did not require surgery and is weight bearing as tolerated. Other than pubic 
rami fractures, which did not require surgery, the enrollee has not had a significant change in the enrollees 
baseline medications. The enrollee does not require 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 enrollees medical and 
rehabilitation needs do not require the intensive interdisciplinary approach provided on acute inpatient 
rehabilitation. 
 
The enrollee 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. As of June 1st, 2023, the enrollee required stand by assistance with 
toileting. The enrollee requires moderate assistance with bed mobility and transfers and ambulating with a 
walker. The enrollee requires significant assistance for lower body dressing. The enrollee has had a decline 
from the enrollees baseline level of function and would benefit from occupational and physical therapies as 
well as supervision and assistance, but the enrollee does not require the intensity of therapies provided on acute 
inpatient rehabilitation. 
 
Therefore, the 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.