Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from March 17, 2022, 
through March 30, 2022. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the inpatient hospital care provided 
was medically necessary. The Plan denied your request. The Plan says that the inpatient hospital care was not 
medically necessary. 
 
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 the 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 that the enrollee was brought to the Emergency Room (ER) for lower back and right 
calf pain related to a fall. He complained of one week of lower back pain and a burning sensation in his right 
foot. On exam, his right leg was numb and weak. He complained of pain and struggled to walk. Neurology 
evaluated and suspected his pain and numbness were caused by nerve damage in the spine. He was admitted for 
further follow-up. He had a Magnetic Resonance Angiography (MRA) that looked at the blood vessels in his 
body, a Computed tomography (CT) scan of his head, Magnetic Resonance Imaging (MRI) of his head, and an 
MRA of his neck. These tests were negative for acute issues and stroke. An MRI and CT scan of his spine 
showed no acute fractures or injury. However, they confirmed he had worsening radiculopathy, severe 
narrowing of his spine, and a severe reduction in the size of the opening in the spinal column. Neuroradiology 
took a second look at his MRI of the spine and noted mass-like lesions in his lower spine concerning a synovial 
cyst, a type of fluid-filled growth. Blood tests were done to test his Erythrocyte Sedimentation Rate and  
C-Reactive Protein levels to determine if there was any inflammation in the body which can be an indicator of 
infection or an inflammatory condition. The results of the blood tests were slightly high. An Interventional 
Radiology biopsy of the cysts was recommended in which they would use a special needle to obtain tissue or 
fluid samples for further examination. This procedure was delayed. They had to hold his blood thinning 
medications for the procedure, and his Neurontin dose had to be decreased due to drowsiness. He also had an 
episode of chest discomfort, but acute issue and heart attack were ruled out. He was cleared to have the biopsy 
on March 28, 2022. He tolerated the procedure well, and outpatient follow-up was recommended.  
 The review has determined 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 the 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 17, 2022, through March 30, 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.