Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from October 7, 2022, 
through October 27, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary.  
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee presented to the emergency department (ED) on October 6, 2022 after a fall. The 
enrollee was recently discharged from a subacute rehabilitation on September 30, 2022. Over the last five days 
the enrollee had been getting progressively weaker. He was unable to toilet himself. The enrollee had a 
decrease in appetite and was not eating. He fell and was unable to get up and hence went to the emergency 
room for further evaluation. The group home where the enrollee resides noticed that he had been having 
increased tremors. They denied any increased weakness in his upper extremities or dropping anything. He was 
admitted for further evaluation. He was seen by Neurology and found to have peripheral neuropathy. 
Neurology had recommended a lumbar puncture (LP). The enrollee tolerated the procedure well. He was 
followed by Neurology; the LP was not significant. Computed tomography (CT) of the thoracic and lumbar 
spine were done. Neurosurgery was consulted secondary to possible spinal stenosis and chronic fracture 
causing his weakness. At this time they recommended outpatient follow-up. The enrollees acute kidney injury 
resolved. The enrollee had been having visual and auditory hallucinations upon arrival. He was evaluated by 
Psychiatry. His medications were titrated. While waiting for rehabilitation, he developed hematuria. Urology 
was consulted and a foley was placed for bladder irrigation. His hematuria resolved and the foley was removed. 
A urinalysis was taken and he was started on empiric antibiotics. He was discharged on October 27, 2022 when 
considered medically stable. 
 
  
 
The review has determined that the record showed that at the time of the inpatient admission the admitting 
physician reasonably expected that the enrollees 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 these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from October 7, 2022, through October 27, 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.