IRF Denial After Stroke: Building the Redetermination
An inpatient rehabilitation facility admits a 72-year-old woman 6 days after a left middle cerebral artery stroke. She has dense right hemiplegia, aphasia, and requires two-person assistance for transfers; she cannot walk. She lives alone in a second-floor apartment. She is medically stable but needs 24-hour nursing for medication management and aspiration precautions. The IRF preadmission assessment documents that she tolerates 2 hours of PT/OT daily plus 30 minutes of speech therapy, and has realistic goals to return home with 24-hour support. The IRF submits a Medicare Part A claim. On day 3, the MAC denies the stay as 'not medically necessary; the patient could receive therapy at a skilled nursing facility or home health.' The IRF's case manager must lead the appeal. The facility has 120 days from the denial notice to request redetermination.
1. Evaluate whether the denial has merit by applying IRF coverage criteria.
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The denial has some merit as the record currently stands because IRF coverage generally requires the patient to need and be able to tolerate at least 3 hours of intensive therapy per day, at least 5 days per week (or 15 hours over 7 days), in an interdisciplinary program with 24-hour nursing and rehab physician oversight. The assessment documents 2 hours of PT/OT plus 30 minutes of SLP, or 2.5 hours, which is below the threshold. However, CMS recognizes that some patients cannot tolerate 3 hours because of their medical condition; the physician must document the reason and why the patient still needs IRF-level intensity. The patient's dense hemiplegia, aphasia, two-person transfers, aspiration precautions, medication management needs, and lack of a home caregiver support medical complexity and 24-hour nursing. But SNFs also provide 24-hour nursing and therapy, so the IRF must show why SNF cannot meet the intensity or physician oversight needs. As written, the MAC can reasonably question the 3-hour requirement. The case manager should first confirm whether the therapy logs actually show 3 hours or a documented exception; if not, the appeal is weak. The denial is not automatically correct, but the documentation must close the gap.
2. Draft the core arguments for a redetermination appeal, including what evidence to attach.
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Request redetermination within 120 days in the format the MAC requires. The appeal letter should address each denial reason, not just assert that rehab is needed. Argue: (1) the patient meets IRF coverage because she needs an intensive interdisciplinary program and 24-hour rehab nursing for aspiration precautions and medication management; (2) the therapy documentation shows 3 hours per day or, if she truly tolerates only 2.5 hours, include a physician note explaining the medical reason for lower tolerance and why IRF intensity is still required; (3) the rehab physician and team set realistic functional goals; (4) the home is a second-floor apartment with no caregiver, so home health cannot safely manage transfers and aspiration risk; (5) SNF is not an adequate substitute because the needed intensity and physician oversight are not available. Attach the preadmission assessment, therapy evaluations and daily logs, nursing notes, medication list, physician orders, and functional outcome measures. Do not alter the record; use addenda only to clarify facts. Include the claim number and dates of service, and keep proof of timely filing.
3. If the redetermination is denied, what are the next appeal levels and deadlines?
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After redetermination, the next level is reconsideration by the Qualified Independent Contractor (QIC), generally within 180 days of the redetermination notice. If reconsideration is unfavorable, the facility may request an Administrative Law Judge hearing within 60 days, provided the amount in controversy meets the threshold. Next is the Medicare Appeals Council within 60 days of the ALJ decision, then federal district court within 60 days after the Council. If the patient is still in the facility and the denial threatens access to care, ask about expedited review. Track every deadline and keep the patient informed with the required notices. The facility should also evaluate whether it can bill the patient; generally, if it followed the notice requirements and the care was not medically necessary, the patient may not be liable, but the rules are specific. The case manager should coordinate with the finance office and legal counsel, and preserve the clinical evidence for each level.