Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from June 6, 2020 through June 9, 2020.

You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says that by
10:12 a.m. on June 6, 2020, the enrollee was stable for safe repatriation by appropriate transport to a Plan facility All inpatient care provided after 10:12 a.m. on June 6, 2020 through 2:00 p.m. on June 9, 2020 was not needed on an emergent basis.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 

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 the inpatient care. Our reviewer says that all inpatient care provided after 10:12 a.m. on June 6, 2020 through 2:00 p.m. on June 9, 2020 was not needed on an emergent basis and does not meet criteria. Our physician reviewer found that the enrollee, with a significant history of chronic hypercapnic respiratory failure, COPD (recent treatment with Methylprednisolone), obstructive sleep apnea, chronic kidney disease, stage 4, Diabetes Mellitus Type 2, diastolic heart failure, a smoker and permanent pacemaker arrived at the non-Plan Emergency Department (ED) on June 5, 2020 via ambulance for a chief complaint of gradual worsening of shortness of breath; he was found hypoxic by paramedics. Upon arrival to the ED, the enrollee was awake and alert, however, became altered and was ultimately intubated. Arterial blood gases revealed hypercarbia and acidosis and his chest X-ray showed congestive heart failure with multifocal infiltrates. His brain natriuretic peptide was elevated, troponin was negative, and he was found to be coronavirus (COVID-19) positive. The enrollee was treated with intravenous (IV) Lasix, steroids, antibiotics, and did not require vasopressors. The enrollee's emergency medical condition improved, and the progress note dictated on June 6, 2020 at 10:12 a.m. deemed him, "hemodynamically stable." The review indicates that as of 10:12 a.m. on June 6, 2021, the enrollee was stable for safe repatriation by appropriate transport to a Plan facility because his acute respiratory distress was stabilized by ventilation and he was started on IV antibiotics for COVID-19 pneumonia, IV steroids, and IV Lasix. He was noted to be in no acute distress and deemed hemodynamically stable; he did not require vasopressors. All inpatient care provided after 10:12 a.m. on June 6, 2020 through 2:00 p.m. on June 9, 2020 was not needed on an emergent basis. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient care provided from June 6, 2020, through June 9, 2020.