Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from February 3, 2022, to 
February 5, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the patient was not stable for discharge 
due to chest pain and nausea. The Plan denied your request. The Plan says that the admission was not medically 
necessary because the patient responded to treatment during the observation period and did not have severe 
findings needing additional treatment. Observation level of care was approved. 
 
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 was a then, 83 year old male with a history of congenital heart disease, coronary 
artery disease status post myocardial infarction, paroxysmal atrial fibrillation, mitral regurgitation, 
hyperlipidemia, and chronic kidney disease Stage IV who presented to the emergency room on February 3, 
2022, with a main diagnosis of displacement of infusion catheter (PICC line) that needed to be replaced for him 
to continue to receive medication for the treatment of his congestive heart failure. The record sent by the 
provider indicated that the home health nurse accidentally cut the PICC line with scissors. A new PICC line 
was placed by the Interventional Radiology. Because the tubing for the PICC line was not available, he was 
kept in the hospital. Cardiology evaluated the patient on February 3, 2022, and he did not have chest pain but 
did report chronic shortness of breath. On February 4, 2022, he had chest pain described as the same chest pain 
that he has at home and is treated with sublinqual nitroglycerin. The electrocardiogram did not show new 
changes and his heart blood levels were elevated but stable. His necessary medicines were continued during the 
hospital stay. He tolerated all treatments and was discharged on February 5, 2022. The record showed that at 
the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital 
care (including earlier emergency room 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 February 3, 2022, to February 5, 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.