Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided on December 13 - December 15, 2019. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollees care could not have been provided in an outpatient environment. The Plan denied your request. The Plan says that there was no documentation provided of specific objective data or treatments explaining why the enrollee could not have been moved to a less intensive setting on the evening of December 14, 2019. 
 
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 presented to the emergency department on December 13, 2019 and was admitted to observation status with the diagnoses of generalized weakness and diabetes type 2. He was changed to inpatient status on December 14, 2019 as his care could not be provided in an outpatient environment. He was discharged on December 15, 2019. The history and physical was done on December 13, 2019 at 17:14 and the enrollee had been planned to be sent home from emergency department, but needed assist of 1 to get out of bed and was unable to ambulate. The enrollee was put in Observation status. At 19:35 on December 14, 2019, the Physician Advisor stated the inpatient stay was going to cross the 2 midnight point. The member's first glucose was on December 13, 2019 at 11:08 but the H&P date/time is the only documentation when the member was admitted from emergency department care. The Discharge Summary was done on December 15, 2019 at 11:28, which is past 2 midnights. On presentation the enrollee had a normal blood pressure, pulse of 85, afebrile, normal respiration rate of 18, and oxygen saturation of 95%. He was not on any intravenous medications or fluids. His blood glucose was under control and his generalized weakness was deconditioning. His condition stabilized and improved and he was discharged home on December 15, 2019. 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 on December 13 - December 15, 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.