Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for acute inpatient hospital care provided February 3, 2019 to February 12, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee met continued inpatient level of care under multiple Medicare care guidelines (Heart Failure Psychiatric disorders). She was not stable for discharge under general discharge criteria and had significant complex commodities with her long-term Parkinson's. The Plan denied your request. The Plan says that the inpatient stay for dates February 03, 2019 to February 12, 2019 were not medically necessary. The member remained stable throughout the stay. 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 documentation supports that the criteria for inpatient payment were met in this case. Our physician reviewer found that the enrollee presented to the emergency department (ED) on February 3, 2019 with a chief complaint of 3 un-witnessed falls in the past 24 hours. The enrollee had a history of dementia and Parkinson's disease. The daughter states she has hallucinations in regards to her Parkinson's. The enrollee has weakness in the legs when walking and falls to the ground. The record stated no weakness was reported. She was treated with intravenous (IV) diuretics and initially IV antibiotics for an infection. On February 03, 2019 she had a chest x-ray for shortness of breath and findings of an enlarged heart were present. She continued with hallucination issues and her medical regimen was adjusted. Her condition stabilized and improved and she was admitted to a skilled nursing facility (SNF) on February 12, 2019. The review has determined that the 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 acute inpatient hospital care provided February 3, 2019 to February 12, 2019.
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.