Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital care for the laparoscopy, surgical, 
esophagogastric fundoplasty (eg, Nissen, Toupet procedures) (CPT code 43280), for the enrollee. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee will need a repeat 
swallow study after the approved procedure. The Plan denied your request. The Plan says this procedure is also 
an outpatient procedure and does not require an inpatient level of care to perform. The Plan states the clinical 
documentation provided does not report poorly controlled co-morbid conditions which would prevent this 
enrollee from having this elective surgical intervention. The Plan states should the enrollee have intra- or post-
operatively requirements for care that meets an inpatient level of services, then the Plan would approve 
inpatient care as an observation conversion. 

The Plan states for these reasons, the surgery remains approved, but pre-operatively, the intensity for an acute 
inpatient level of care is not met and the inpatient DRG coverage is not approved on reconsideration review. 
The Plan states they will cover inpatient services if the enrollee's condition intra- or post-operatively warrants 
that intensity of care. 
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the review indicates that the enrollee has a history of hypertension for 
which they take Metoprolol. The enrollee also has a history of diabetes mellites and takes Metformin. These 
comorbidities appear to be well controlled. The enrollee is noted to have no significant uncontrolled chronic 
conditions that pre-operatively would warrant an in-patient level of care. The enrollee is medically stable. The 
Plan states should the enrollee have intra- or post-operatively requirements for care that meets an inpatient 
level of services, then the Plan would approve inpatient care as an observation conversion. The review has 
determined that the record does not show the admitting physician reasonably expects that the enrollee's 
necessary hospital care will 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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient hospital care for the laparoscopy, surgical, esophagogastric 
fundoplasty (eg, Nissen, Toupet procedures) (CPT code 43280), for the enrollee.