Why Anthem BCBS Denies Inpatient Rehabilitation Facility (IRF)
Patient does not require 3 hours/day therapy intensity
Skilled nursing facility is appropriate alternative
Medical complexity does not warrant IRF level
Know Anthem / Blue Cross Blue Shield's Criteria
Anthem uses their own Clinical UM Guidelines and AIM Specialty Health for imaging. Medical policy numbers are publicly searchable.
Key policies to know:
- AIM Specialty Health manages imaging prior auth
- Clinical UM Guidelines searchable at anthem.com/provider
- Known for strict imaging prior auth requirements
- Uses evidence-based medicine approach with published policies
Building Your Medical Necessity Argument
Document ability to participate in 3+ hours/day of therapy
List qualifying diagnoses under the 60% rule
Note medical complexity requiring physician supervision
Explain why SNF level is insufficient for this patient
P2P Call Tips for Anthem BCBS
Reference specific Anthem Clinical UM Guideline by policy number
For imaging, address AIM criteria specifically
Anthem medical directors appreciate evidence-based arguments
Cite specific clinical criteria being met from their own policy
Guidelines to Reference
- CMS IRF Coverage Requirements (60% Rule)
- InterQual Criteria for Rehabilitation Facility Admission
Relevant CPT Codes
Specialty: Physical Medicine & Rehabilitation
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