Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve continued acute inpatient hospital care. 
 
You asked the Plan to pre-approve continued acute inpatient hospital care. You say that the procedure has to be 
done inpatient. The enrollee requires a heparin drip due to bleeding from 01/06/2023 through 01/08/2023. The 
Plan denied your request. The Plan says that inpatient level of care beyond 1/7/2023, is not medically 
necessary. The enrollee does not meet the requirements for ongoing inpatient care needs. The records indicate 
that the enrollee is medically stable for discharge. The records also indicate that all further workup is to be 
done as an 
outpatient. 
 
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 continued acute inpatient hospital care. 
Our reviewer says that the documentation supports that the criteria for continued inpatient hospital care is met 
in this case. Our physician reviewer found based on how the enrollee described discomfort with BM, blood 
mixed with normal brown stool and stable H/H & hemodynamics, bleeding appears to be hemorrhoidal in 
origin with +/- mucosal oozing from inflammation currently while on AC and C. diff colitis. The plan was to 
continue Fidaxomicin, topical hemorrhoid therapy, Anusol suppository bid, and ok to continue heparin gtt for 
now & monitor clinically with trending H/H; KBU to evaluate abdominal tightness and pain looking for 
worsening colonic dilation; can resume diet if KUB unremarkable; no endoscopic interventions planned 
currently, if the enrollee continues to have significant bleeding or > 3 gram drop in hemoglobin. The family 
notes he has some anxiety. Notes addition of Mirtazapine has helped with sleep. MDD in partial remission, 
Adjustment d/o w/anxiety and consider mild cognitive impairment. The enrollee is feeling well and ready to go 
to rehab. Discontinue heparin drip and restart Eliquis. Nursing reports with decreased diarrhea over the past 
several days and no behavior concerns. The review has determined that the record shows 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 continued acute inpatient hospital care have been met. Therefore, we decided 
that the Plan has to pre-approve continued acute inpatient hospital care.  
 
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.