Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from December 20, 2020, through December 30, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically necessary. The Plan denied your request. The Plan says that an inpatient level of care was not medically necessary. The services rendered could have been delivered in a short stay (observation) level of care with discharge follow-up on an outpatient basis.

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 in this case, the record indicates that the enrollee was admitted with hypertensive heart disease and heart failure. Upon presentation the enrollee, who has multiple comorbidities, became dyspneic walking across the room, had gained over 20 pounds in fluid weight in less than two months. The enrollee had a room air oxygen saturation of 87%. The enrollee was originally placed in observation but remained dyspneic with worsening hypoxia and was admitted to inpatient status. The enrollee was borderline hypotensive which complicated diuresis. The decision to admit as an inpatient should generally be based on the treating physician's reasonable expectation of a length of stay spanning 2 or more midnights, taking into account complex medical factors that must be documented in the medical record. Because this is based upon the physician's expectation, as opposed to a retroactive determination based on the actual length of stay, unforeseen circumstances that result in a shorter stay than the physician's reasonable expectation may still result in a hospitalization that is appropriately considered inpatient. The enrollee failed a period of observation and was then appropriately admitted. The elements of the coverage rule are satisfied. The requested service is recommended.

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 December 20, 2020, through December 30, 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.