Why MA Plans 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 Medicare Advantage's Criteria
Medicare Advantage plans must cover all services covered by Original Medicare (CMS NCDs and LCDs) but may require prior auth. Plans use various criteria including InterQual, MCG, and proprietary guidelines.
Key policies to know:
- Must cover all services covered by Original Medicare
- Can require prior authorization not required by Original Medicare
- CMS NCDs and LCDs serve as coverage floor
- Organization determinations must be issued within 14 days (72 hours for expedited)
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 MA Plans
Cite the relevant CMS NCD or LCD -- MA plans cannot deny what Medicare covers
If the service has a CMS NCD, that trumps the MA plan's internal criteria
Reference CMS regulations on MA coverage obligations
Request expedited determination if clinical urgency exists
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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