Reviewing for Intensive Level of Rehabilitation Therapy Services

6.7.1 – Reviewing for Intensive Level of Rehabilitation Therapy Services Requirements (Rev. 10184; Issued: 06-19-2020; Effective: 07-21-2020; Implementation: 07-21- 2020) When reviewing IRF claims, the UPIC, MAC, SMRC, CERT and RAC shall verify that the IRF documentation requirements are met in accordance with IOM 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110. The UPIC, MAC, SMRC, CERT and RAC shall not make absolute claim denials based solely on a threshold of therapy time not being met. When the current industry standard of generally 3 hours of therapy (physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics) per day at least 5 days per week or at least 15 hours of intensive rehabilitation therapy within a 7 consecutive day period is not met, the claim shall undergo further review. The UPIC, MAC, SMRC, CERT and RAC shall use clinical review judgment to determine medical necessity of the intensive rehabilitation therapy program based on the individual facts and circumstances of the case, and not on the basis of any threshold of therapy time. The standard of care for IRF patients is individualized (i.e., one-on-one) therapy. Group and concurrent therapy can be used on a limited basis within the current industry standard of generally 3 hours of therapy per day at least 5 days per week or at least 15 hours of intensive rehabilitation therapy within a 7-consecutive day period. In those instances in which group therapy better meets the patient’s needs on a limited basis, the situation/rationale that justifies group therapy should be specified in the patient’s medical record at the IRF. However, MAC, SMRC, CERT and RAC shall not deny solely because the situation/rationale that justifies group therapy is not submitted in response to an ADR.