Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from March 7, 2022, to 
March 9, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this admission was medically 
necessary. The Plan denied your request. The Plan says that this admission was not medically necessary 
because the patient could have be managed in a lower setting. The patient did not require admission for 
hemodialysis. 
 
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 is a 77 year-old male with a history of chronic obstructive pulmonary disease, 
diabetes mellitus, hypertension, and renal disorder on hemodialysis. He was brought in by the Paramedics to 
the Emergency Department on March 7, 2022, due to hypotension. He reports that he was 20 minutes into his 
dialysis treatment when he started to feel weak, dizzy, and short of breath. The nurse at the dialysis center 
noted his blood pressure was in the 70s and when rechecked it did not improve. Paramedics noted his blood 
pressure at 106/50, and on arrival to the Emergency Department patient stated he felt weak. On exam, his vital 
signs showed blood pressure of 124/64, pulse rate 90, respiratory rate 16, temperature 36.8 and oxygen 
saturation of 99%. His lab results were RBC 3.46, Hgb 11.0, Hct 33.6, platelets 96, potassium 5.9, BUN 72.2, 
creatinine 9.6, eGFR 5.3, troponin T 0.359, magnesium 2.80, glucose 119. Chest x-ray revealed a mild infiltrate 
noted within the right perihilar region and right lower lung zone with partial silhouetting of the right heart 
border and right hemidiaphragm. Cardiomegaly without evidence of frank congestive failure. The patient was 
admitted for renal management, dialysis, hypotension, and correction of electrolytes. On March 8, 2022, his 
vital signs showed BP 133/71, PR 89, RR 20, T 36.6, SpO2 96%. On 03/09/22, he had dialysis and was doing 
well, his blood pressure was well controlled on antihypertensive medications. He was hemodynamically stable 
and was renally cleared for discharge. 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 the acute inpatient hospital care provided from March 7, 2022, to March 9, 2022.  
 
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.