Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided on August 5 -August 7, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the records provided support the level of care in dispute.The Plan denied your request. The Plansays that the enrollee did not have to be admitted to the hospital in order to get the care needed. The Plan says that the enrollee's care could have been given at the 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 the enrollee was brought in by medics on August 5, 2019 to the provider for an emergency evaluation due tonew-onset chest pain in the setting of recent increased shortness of breath, dyspnea on exertion, and cough. The medical record indicates that the enrollee was a very limited historian due to her underlying dementia and emergency medical services (EMS) had found elevated carbon monoxide in the house due to stove being left on. On initial presentation, the enrollee was afebrile (temperature of 98.1 degrees Fahrenheit) and severely hypertensive (blood pressure of 221/96 mmHg) with a pulse of 83 beats per minute, a respiratory rate of 20 breaths per minute, and an oxygen saturation of 100% on room air. On examination, the enrollee had bilateral crackles and wheezing. Laboratory studies were remarkable for microcytic anemia (hemoglobin 8.3 g/dl with MCV 71.5 fi), hypematremia (sodium 148 mmol/L), hypokalemia (potassium 3.0 mmol/L), and hypomagnesemia (magnesium 1.4 mg/dl). An electrocardiogram (ECG) demonstrated normal sinus rhythm with heart rate measuring 97 beats per minute, left ventricular hypertrophy, and prolonged QTc measuring 518 milliseconds. A chest radiograph demonstrated evidence of interstitial disease. In the emergency department, the enrollee was administered intravenous methylprednisolone, multiple duo-nebulizers, intravenous famotidine, intravenous thiamine, and oral clonidine 0.1 mg. The enrollee required acute inpatient care for the management of acute chest pain, shortness of breath, and cough. The treating physician's clinical impression was emergently concerned for acute hypertensive urgencyand an acute chronic obstructive pulmonary disorder (COPD) exacerbation, likely precipitated by acute bronchitis. The enrollee also had multiple electrolyte abnormalities including hypokalemia and hypomagnesemia associated with QTc prolongation, which placed her at risk for developing an acute arrhythmia. The treating physician's evaluation plan and treatment course for the enrollee consisted of intravenous methylprednisolone 40 mg every 8 hours, intravenous doxycycline 100mg twice daily, intravenous ceftriaxone 1 gram daily, duo-nebulizers every 4 hours, supplemental oxygen, losartan 100mg daily, memantine 5mg twice daily, electrolyte repletion as needed, serial blood chemistries, CT chest, telemetry monitoring, and Neurology Consultation. Computed tomography (CT) of the chest demonstrated centrilobular emphysema with bilateral ground glass opacities concerning for pulmonary vascular congestion, and cardiomegaly. Due to persistent uncontrolled hypertension, the enrollee required up-titration of anti-hypertensive medications with the addition of nifedipine 60 mg daily and hydralazine 25 mg every 8 hours. The enrollee's condition stabilized and improved and she was discharged when considered medically stable on August 7, 2019. The review has determined 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 forthe acute inpatient hospital care provided on August5 -August 7, 2019.