Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from September 15, 2022, to 
September 27, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee's medical information and 
the attending physician's decision to admit support inpatient level of care. The Plan denied your request. The 
Plan says that the enrollee did not need acute inpatient admission after a 2-day observational level of care with 
improved mentation. 
 
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 admitted on September 15, 2022 for continued COVID-19 management after 2 
days of observation level of care for altered mental status and acute kidney injury. The enrollee has a history of 
dementia. The enrollee tested COVID-19 positive upon admission. The enrollee was able to take food, fluids, 
and medications orally. The enrollee was afebrile. The enrollee's oxygen saturation was 96% on room air and 
did not require oxygen supplementation. Infectious Disease specialty was consulted and documented to hold 
off initiation of COVID-19 treatment as the enrollee continued to remain on room air. Laboratory tests showed 
no leukocytosis. The enrollee did not require antibiotics. A chest X-Ray showed interstitial prominence, 
chronic lung changes verse early edema/infection were not excluded. The enrollee received intravenous fluids 
with improved renal function with creatinine decreasing from 1.76 on September 13, 2022, to 1.33 on 
September 15, 2022. The enrollee had a swallowing evaluation performed on September 15, 2022 which 
allowed a pureed diet with thin liquids with aspiration precautions. The enrollee was discharged on September 
27, 2022 when considered medically stable. At the time of inpatient admission, the admitting physician 
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or 
observation care) would span at least 2 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 September 15, 2022, to September 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.