Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 5, 2020, through November 8, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the medical record support the medical necessity The Plan denied your request. The Plan says that medical care could have been provided at an 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 was a then, a 64-year-old female who presented to the Emergency Department on November 5, 2020 for evaluation of severe, worsening abdominal pain, hematemesis and black diarrhea. She was admitted for inpatient level of care on November 6, 2020. The documentation indicates that enrollee presented from clinic with three weeks of worsening epigastric pain, similar to what she had in the past. She had nausea and vomiting and loose and dark stool. She took 40 mg omeprazole at home, and OxyContin 20 mg. She had Zofran and oxycodone as PRN meds. The H&P did not document if these were used or frequency of vomiting, but noted she reported poor oral intake. Surgery has seen her and no interventions at that time. The cause of her symptoms was not known. Her hemoglobin was at baseline. The plan was to continue pain management with Tylenol, OxyContin 20, and dicyclomine 20 mg Q8H PRN. Despite her taking those by mouth, they put her on pantoprazole 40 mg IV BID. Senna, docusate, and Miralax for constipation, and made NPO for now, with IVF. GI consult was completed on November 6, 2020. The assessment noted she may once again have a marginal ulcer but less likely it is actively bleeding. She had an EGD showing a healing ulcer. The plan was to continue to monitor her for signs of bleeding or perforation. An EGD could wait until Monday the 9th. The GI attending noted her would have scoped her that day, but the hospital did not prevent her from eating.
The November 7, 2020, 12:41 note mentioned she was given her home dose of 5 mg oxycodone some time overnight (MAR shows 05:03 on November 8, 2020), then she was in severe pain, so they chose to give 1 mg Dilaudid. As oxycodone normally lasts 4 hours, and they gave her home dose and not higher and did not document her response, it is not clear why they resorted to that rather than a higher oral dose. The MAR shows she often (4-5 per day) was getting the PRN dose, but never upped the OxyContin or used a higher PRN dose. The Dilaudid was given November 7, 2020 at 09:04 and 12:16 and November 8, 2020 at 01:16, so this was 4 hours after her oxycodone at 5:03.
The November 8, 2020 note stated no overnight events and she was asking for breakfast. She was sent home and the EGD was planned to be done as an outpatient. The review indicates that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee'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 5, 2020, through November 8, 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.