Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an inpatient hospital admission. 
 
You asked the Plan to pre-approve an inpatient hospital admission. You say that the enrollee was confused and 
had a high fever. He had significant shortness of breath and worsening hypoxemia while on maintenance CPAP 
and oxygen. The enrollee was unsafe for discharge due to the needed management for the enrollee's recurrent 
hypoxic hypercapnic respiratory failure and felt to be related to the enrollee's severe COPD, morbid obesity, 
generalized weakness and poor mobility with risk of COPD exacerbation and monitoring for heart failure. The 
Plan denied your request. The Plan says that the enrollee's records do not indicate that his needs could not be 
met at a lower level of care. The inpatient admission remains upheld based on lack of medical necessity for the 
services. 
 
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 pre-approve inpatient hospital admission. Our 
reviewer says that the documentation supports that the criteria for inpatient hospital admission is met in this 
case. Our physician reviewer found the review indicates that the enrollee with a history of severe COPD, 
morbid obesity, generalized weakness and poor mobility presented to the emergency room on March 1, 2023, 
after discharge from a skilled nursing facility. He was placed in observation for facility placement. In the early 
morning of March 6, 2023, he was found to have a fever of 102.8 and oxygen saturation of 88% on his standard 
CPAP. He was placed on BiPAP 60%. He remained hemodynamically stable. He had no further fevers. He 
remained alert and oriented on O2 4lpm with oxygen saturations greater than 90%. It was noted that his normal 
home O2 was 3lpm. He had a CT scan of the brain that showed no evidence of stroke. His medications were 
not changed. His chest x-ray did not reveal evidence of acute heart failure. There was no source of his isolated 
fever episode. The review indicates that the record showed that at the time of inpatient admission the admitting 
physician reasonably expected that the enrollees 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 inpatient hospital admission have been met. Therefore, we decided that the Plan 
has to pre-approve an inpatient hospital admission.   
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.