Medicare Coverage Requirements: IRF
30 federal coverage criteria from Medicare Benefit Policy Manual, Chapter 1 Section 110: Inpatient Rehabilitation Facility (IRF) Services, with CMS page references. These are the Medicare requirements used when evaluating denial reasoning.
Rev. 10892 (2021) (14 pages)
The patient does not have to be expected to achieve complete independence in the domain of self-care or return to his or her prior level of functioning. The IRF medical record must demonstrate that the patient is making functional improvements that are ongoing and sustainable, as well as of practical value, measured against his/her condition at the start of treatment.
p. 14Medical Necessity Criteria (All Five Required)
ALL five criteria must be met for IRF admission to be considered reasonable and necessary.
The patient must require the active and ongoing therapeutic intervention of multiple therapy disciplines (physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics), one of which must be physical or occupational therapy.
The patient must generally require an intensive rehabilitation therapy program. Under current industry standards, this generally consists of at least 3 hours of therapy per day at least 5 days per week. In certain well-documented cases, this might instead consist of at least 15 hours of intensive rehabilitation therapy within a 7 consecutive calendar day period, beginning with the date of admission to the IRF.
The 3-hour rule is a general expectation, not a hard daily minimum. The 15-hour/7-day alternative allows flexibility.
The patient must reasonably be expected to actively participate in, and benefit significantly from, the intensive rehabilitation therapy program. The patient must be expected to make measurable improvement that will be of practical value to improve the patient's functional capacity or adaptation to impairments.
The patient need not be expected to achieve complete independence in the domain of self-care nor be expected to return to his or her prior level of functioning in order to meet this standard.
The patient must require physician supervision by a rehabilitation physician. The rehabilitation physician must conduct face-to-face visits with the patient at least 3 days per week throughout the patient's stay in the IRF.
Beginning with the second week, a non-physician practitioner may conduct 1 of the 3 required face-to-face visits per week.
The patient must require an intensive and coordinated interdisciplinary approach to providing rehabilitation.
Preadmission Screening (Within 48 Hours)
A comprehensive preadmission screening must be performed within 48 hours immediately preceding the IRF admission.
Documentation of the patient's prior level of function (prior to the event or condition that led to the patient's need for intensive rehabilitation therapy).
Expected level of improvement and the expected length of time necessary to achieve that level of improvement.
An evaluation of the patient's risk for clinical complications.
The conditions that caused the need for rehabilitation, and the treatments needed (i.e., physical therapy, occupational therapy, speech-language pathology, or prosthetics/orthotics).
Anticipated discharge destination.
The rehabilitation physician must document his or her review of and concurrence with the results of the preadmission screening prior to the IRF admission.
Timing Requirements
Key time-bound requirements for IRF admission and treatment initiation.
Preadmission screening must occur within 48 hours immediately preceding the IRF admission.
A screening done more than 48 hours before admission is accepted if an update is conducted (in person or by telephone) within the 48-hour window to document current medical and functional status.
An overall plan of care must be completed within the first 4 days of the IRF admission.
Rehabilitation therapy must begin within 36 hours from midnight of the day of admission.
Therapy evaluations are generally considered to constitute the beginning of the required therapy services.
Brief exceptions to the intensive therapy program are permitted when an unexpected clinical event limits the patient's participation for a period not to exceed 3 consecutive days.
Examples: diagnostic tests, chemotherapy infusion, bed rest for DVT, surgical procedure. This does not automatically end coverage.
Interdisciplinary Team Requirements
The composition and function of the required interdisciplinary team.
Team must include a rehabilitation physician.
Team must include a registered nurse with specialized training or experience in rehabilitation.
Team must include a social worker or a case manager (or both).
Team must include a licensed or certified therapist from each therapy discipline involved in treating the patient.
Team conferences must occur at least once per week to assess the patient's progress and modify the treatment program as needed.
Measurable Improvement Standard
What CMS means by 'measurable improvement' in the IRF context. Denials frequently overstate this standard.
Improvement must be measurable and of practical value to the patient, measured against the patient's condition at the start of treatment.
Complete independence in the domain of self-care is NOT required. The patient need not be expected to achieve complete independence to meet this standard.
Return to the patient's prior level of functioning is NOT required. Functional improvements that are ongoing and sustainable, as well as of practical value, measured against his/her condition at the start of treatment, meet the standard.
Common Denial Traps
Criteria frequently cited in IRF denials that do not match what CMS policy actually requires.
TRAP: Denial requires exactly 3 hours of therapy every day. POLICY: 3 hours/day is a general expectation. The alternative is at least 15 hours within a 7 consecutive calendar day period starting from the date of admission.
The 3-hour rule is not a hard daily minimum.
TRAP: Denial says therapy did not begin within 36 hours. POLICY: Therapy must begin within 36 hours from midnight of the day of admission (not from the time of admission).
TRAP: Denial says patient cannot achieve complete independence. POLICY: Complete independence is NOT required. Practical improvement to a less dependent level is sufficient.
TRAP: Denial requires return to prior function. POLICY: Return to prior level of function is NOT required. Sustained practical improvement meets the standard.
TRAP: Patient does not have one of the 13 qualifying conditions. POLICY: The 13 conditions are used for the 60% compliance threshold at the facility level. They are NOT per-claim admission requirements.
60% compliance is a facility classification rule, not an individual patient eligibility rule.
TRAP: Denial cites missing post-admission physician evaluation. POLICY: This requirement was removed in FY 2021 (85 FR 48424). It is no longer a valid basis for denial.
TRAP: Denial cites InterQual, MCG, or proprietary UM criteria. POLICY: These are not CMS coverage criteria. MA plans may not apply criteria more restrictive than Traditional Medicare standards.
13 Qualifying Conditions
Conditions listed in 42 CFR 412.29(b)(2). Used for the 60% compliance threshold at the facility level. These are NOT per-claim admission requirements. Denials that cite these conditions as individual patient eligibility criteria are misapplying the regulation.