Appeal type: Surgery
Decision: Partially Favorable

 We decided that the Plan has to pre-approve transoral fundoplication and inpatient admission. We decided that the Plan does not have to pre-approve the requested inpatient admission.   You asked the Plan to pre-approve transoral fundoplication and inpatient admission. You say that this treatment is medically necessary for the patient's gastroesophageal reflux disease. The Plan says that Medicare studies haven't proved that the procedure is helpful for treatment of the enrollee's condition.  We decided that the Plan has to pre-approve transoral fundoplication.   The Plan follows Medicare rules. Medicare rules say that services are only covered when medically necessary.  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 transoral fundoplication and inpatient admission. Our reviewer says that transoral fundoplication is medically necessary, but the requested and inpatient admission is not medically necessary. Our physician reviewer found that the record indicates that the enrollee has gastroesophageal reflux that is refractory to proton pump inhibitor therapy.  The recommendation is to proceed with the requested transoral fundoplication procedure. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has provided a favorable recommendation for the requested procedure. The elements of the coverage criteria are satisfied.  However, the second issue  is whether inpatient services for the enrollee is a covered service under Medicare rules. If the patient requires medically necessary hospital care that is expected to span 2 or more midnights, then inpatient admission is generally appropriate.  If the physician expects the patient's medically necessary treatment to span less than 2 midnights and NOT involve services designated by CMS as inpatient-only, it is generally appropriate to treat the patient in outpatient status.  The decision to admit as an inpatient should generally be based on the treating physician's reasonable expectation of a length of stay spanning 2 or more midnights, taking into account complex medical factors that must be documented in the medical record.  Because this is based upon the physician's expectation, as opposed to a retroactive determination based on the actual length of stay, unforeseen circumstances that result in a shorter stay than the physician's reasonable expectation may still result in a hospitalization that is appropriately considered inpatient. If the physician is uncertain whether the patient will be able to be discharged after 1 midnight in the hospital or whether the patient will require a second midnight of care, the initial day should be spent in observation until it is clearly expected that a second midnight would be required, at which time the physician may order inpatient admission. In this case, the record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. The enrollee may be admitted for observation.  The elements of the coverage rule are not satisfied.  The requested inpatient service is not recommended.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of transoral fundoplication have been met. Therefore, we decided that the Plan has to pre-approve transoral fundoplication. We also decided that the Plan does not have to pre-approve the requested inpatient 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.