Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 30, 2020 to December 3, 2020.

You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that the inpatient stay was consistent with observation level of care.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the emergency department (ED) on November 30, 2020 after a fall at her living facility. She was evaluated. While in the ED, Cardiology indicated that the enrollee's elevated troponin was most likely a result of her heart failure. Recommendation was an echocardiogram in the next 1-2 days. There were no emergent recommendations. Neurosurgery reviewed the member's CT cervical spine image, and stated odontoid fracture appeared chronic. Recommended MRI without contrast followed by flexion/extension images if MRI findings appeared chronic. The documentation clearly indicated consideration for discharge back to the enrollee's living facility from the ED if the enrollee's level of care could be increased. An MRI Cervical Spine without contrast was ordered on November 30, 2020 and scheduled for
December 1, 2020. The MRI was delayed until December 2, 2020 due to an emergent case. The MRI was completed and revealed non-displaced type II dens fracture. Suspected disruption of the anterior longitudinal ligament, although the posterior longitudinal, alar, and transverse ligaments appear intact. Her condition stabilized and improved, and she was discharged back to the facility on December 3, 2020. The review indicates that the medical record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from November 30, 2020 to December 3, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.