Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee has been in the 
hospital for 7 days for anemia, profound progressive deconditioning and weakness, malnutrition. The Plan 
denied your request. The Plan says that the request is not medically necessary because the records show the 
enrollee does not have severe anemia or symptoms associated with worsening anemia and has not required 
treatment in an inpatient setting. 
 
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 supports that the criteria for inpatient hospital care is met in this case. Our 
physician reviewer found the enrollee with diastolic heart failure, hypertension, diabetes, neuropathy, chronic 
anemia bilateral lower extremity lymphedema, nutrient malabsorption s/p Roux-en-Y, asthma, recent 
pulmonary embolism on Xarelto, pulmonary hypertension, asthma, depressive disorder, obstructive sleep apnea 
admitted to the hospital on April 28,2023, after he was seen in the emergency department (ED) for trouble 
getting out of the chair at home and unable to ambulate at home. The records indicate the enrollee was recently 
hospitalized in March 2023, for a mechanical fall and generalized weakness and discharged to a skilled nursing 
facility (SNF). The enrollee was discharged from the SNF on April 27, 2023. Generalized weakness due to 
deconditioning, however likely multifactorial contributing factors likely include worsening depression and 
chronic anemia Impaired nutrient absorption r/t Roux-en-Y AEB need for vitamin/mineral supplementation. 
Recent B12, TSH wnl -GGT wnl and persistent elevated alk phos is likely then malnutrition considering 
normal calcium levels, increased home SSRI. Recent anemia labs done at last admit, anemia could be 
contributing to clinic picture-neurology consulted, CT head: negative - Zinc low - continue supplement - 
serum, B6, folate, vitamin D - all normal B1, Copper homocystine still pending - SPEP with immunofixation - 
polyclonal IgG4 (c/w allergies, autoimmune d/o, desensitization tx, certain infections, vasculitis) -PT/OT - 
appreciate rec/care. The review has determined that the record showed that at the time of inpatient admission 
the admitting physician reasonably expected that the enrollee's 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pre-approve acute inpatient hospital care.  
 
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.