by the physician and the rehabilitation team to be needed by the patient on a priority basis would quality toward satisfaction of the rule (HCFA Ruling 85–2). (5) This language allowed physicians with specialized training and experience in inpatient hospital rehabilitation to prescribe the mix of skilled therapies and services appropriate to meet the needs of each individual patient in order to satisfy the Three Hour Rule in the inpatient rehabilitation hospital or unit setting. (6) CMS by regulation (74 Fed. Reg. 39811 (August 7, 2009)) revised these prior requirements, effective January 1, 2010. The Secretary of Health and Human Services acknowledged that he is bound by the court’s decision in Hooper v. Sullivan that rules of thumb , including the Three Hour Rule, may not be imposed to deny IRF coverage. The Secretary stated that he would monitor the appropriateness of instances where IRFs demonstrate the required level of intensity without meeting the Three Hour Rule. (7) The Secretary’s 2010 regulation limited the Three Hour Rule to recognize only 4 skilled services (namely, physical therapy, occupational therapy, and speech language pathology services as well as orthotics and prosthetics) and required that the patient’s physician must certify that the patient requires, at admission, at least 2 of the 4 therapy modalities, one of which must be either physical therapy or occupational therapy. The Secretary’s 2010 regulation removed the discretion of the physician, in consultation with the rehabilitation team, to prescribe other skilled modalities and therapeutic services needed by the patient that would count toward satisfaction of the Three Hour Rule. As a result, the full complement of medically necessary, skilled therapy services may not be available to inpatient rehabilitation hospital patients as part of their plan of care. (8) Skilled, therapeutic modalities in addition to physical therapy, occupational therapy, speech language pathology services, and orthotic and prosthetic services that should be