Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care for an elective 
decompressive lumbar laminectomy of levels L3-S1 (CPT code(s): 63048 X 3, 63047 X 1, and 69990 X 1) for 
the enrollee. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee is in severe pain and the 
pain is affecting their daily activities and causing walking problems. The Plan denied your request. The Plan 
says the planned procedure listed under CPT code 63048, 63047 and 69990 is not listed on the CMS Inpatient 
Only List. The Plan states the procedure is currently approved as an ambulatory procedure. The Plan states 
there is no documentation provided to support the expectation the enrollee will require a greater than two (2) 
midnight stay.  The Plan states if the enrollee experiences any peri- or post-operative complications, reconsideration for 
inpatient level of care can be performed on concurrent review with updated clinical information. 
 
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 does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee has failed conservative management. The health plan feels that the 
services are reasonable and medically necessary for the treatment of the enrollee. The health plan is upholding 
the denial of the preservice request for an inpatient admission. The Health Plan must follow Centers for 
Medicare & Medicaid Services (CMS) rules and guidance per Medicare Benefit Policy Manual Chapter 1 and 
the CMS Inpatient Only List. The enrollee is undergoing a planned decompressive lumbar laminectomy of 
levels L3-S1. The enrollee is medically stable and has been provided medical clearance to undergo this elective 
procedure. The planned procedure listed under CPT code 63048, 63047 and 69990 is not listed on the CMS 
Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no 
documentation provided to support the expectation the enrollee will require a greater than two (2) midnight 
stay. The review has determined that the record does not show that 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 pay for the acute inpatient hospital care for an elective decompressive lumbar 
laminectomy of levels L3-S1 (CPT code(s): 63048 X 3, 63047 X 1, and 69990 X 1) for the enrollee.