Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve acute inpatient hospital care. We decided that the Plan does not 
have to pre-approve IRF care.  
 
You asked the Plan to pre-approve acute inpatient hospital care and acute inpatient rehabilitation facility (IRF) 
admission and services.. You say that the services are medically necessary. The Plan says that the requested 
services are not medically necessary. 
 
We decided that the Plan has to pre-approve acute inpatient hospital care.  
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our 
reviewer says that the service is medically necessary. Our physician reviewer found the record showed that at 
the time of inpatient admission the admitting physician reasonably expected that your necessary hospital care 
(including earlier emergency department and/or observation care) would span two midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve acute inpatient hospital care.  
 
We also decided that the Plan does not have to pre-approve IRF care. 
 
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 
service is not medically necessary. Our physician reviewer found the complexity of your nursing, medical and 
rehabilitation needs did not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You did not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. There was not a reasonable expectation 
that you would 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 IRF care. 
 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.