Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from November 6, 2020, to
November 8, 2020.

You asked the Plan to pay for inpatient or post stabilization care. You say that this admission should be
covered by the Plan. The Plan denied your request. The Plan says the enrollee was stable for transfer. Maximus
upheld or agreed with the Plans denial. Maximus received additional information from your office questioning
our decision. Maximus reopened the decision and sent the case to the Medical Director for review.

Our Medical Director looked at the case file and the reopen request. At issue in this case is coverage for
inpatient care and stability for transfer. The Maximus Physician Reviewer determined that the inpatient care in
this case was not medically reasonable and necessary. The reviewer found that as of 4:01 PM on November 6,
2929, the enrollee was stable for transfer. All inpatient care provided after 4:01 PM on November 6, 2020 to
8:00 AM on November 8, 2020, was not needed on an emergent basis. The enrollee was hemodynamically
stable, and appropriate for ambulance transport with monitoring to an in-plan facility for continued hospital
level of care services. The post-stabilization care at the non-Plan facility was not medically necessary or
reasonable. 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. Your office requested a reopen. The provider stated
the enrollee was unstable for transfer, and that a case manager made the plan aware of the enrollee's condition,
pertaining to continued hospital stay. "However, the provider never heard back from the Plan." The provider argues
that the beneficiary had persistent tachypnea ranging between 19-38 breaths/min and was diagnosed with
asthma exacerbation and acute diastolic congestive heart failure. Hence, continued inpatient stay was required
for treatment with IV Corticosteroids, IV antibiotics, and IV diuretics throughout the stay. The provider notes
that the health plan only approved and paid for, partial days and denied for remaining days, although the
reimbursement type is DRG. "the Plan did not follow the Federal and State regulations by denying inpatient care,
irrespective of the fact that physician has documented that patient was unstable for transfer. By denying
inpatient services for their own failures, the Plan is trying to reduce reimbursement to the provider for the medically
necessary care provided to the beneficiary." The provider notes that DRG methodology does not reimburse
based on a per day basis, but rather per admission. "Health plan only approved and paid for partial days
(11/05/2020-11/06/2020) and denied for remaining days although reimbursement type is DRG."

The medical records in the case file, the reopening request, and the medical review show the enrollee was an
87-year-old woman with a history of heart disease, asthma, hypertension, and chronic pain. The enrollee
presented to the hospital on November 5, 2020 with shortness of breath and non-productive cough. She was in
moderate to severe respiratory distress, with coarse expiratory wheezes in all lung fields. A chest X-ray
demonstrated no airspace pneumonia, pleural effusion, or pulmonary edema. The enrollee was admitted to the
hospital. An infectious disease consultation on November 5, 2020 at 2:58 PM documented that the enrollee was
in no distress on room air, with decreased breath sounds at the bases, and a respiratory rate of 18/minute. The
heart sounds were normal with a heart rate of 74/minute. Blood pressure was elevated. A cardiology
consultation on November 6, 2020 at 2:13 PM documented that the enrollee was in no distress, with a
respiratory rate of 18/minute. Respirations were unlabored, and the lungs were clear to auscultation bilaterally.
Heart sounds were normal with a heart rate of 68/minute. Blood pressure was modestly elevated. An EKG and
an echocardiogram were to be ordered. An infectious disease progress notes on November 6, 2020 3:57 PM
documented a respiratory rate of 18/minute, with decreased breath sounds at the bases.

Determinations of medical necessity by Maximus physician reviewers are tailored to the individual patient and
their unique clinical scenario. In this case, a Maximus Physician Reviewer, with appropriate expertise and
qualifications, rendered an unbiased and well-considered opinion. The medical review was appropriate and
well-supported by documentation in the case file. The documentation supports that the enrollee in this case was
stable for transfer by ambulance to an in-plan hospital on November 6, 2020 at 4:01 PM. Medicare criteria for
continued inpatient care were not met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient or post stabilization care have not been met. Therefore, we decided
that the Plan does not have to pay for inpatient care provided from November 6, 2020, to November 8, 2020.