Court Opinion

ID: 9390338
Source: CourtListenerOpinion
Date Created: 2023-04-27 16:01:07.961616+00
Date Added: 2024-06-11T17:18:33.701740
License: Public Domain

USCA11 Case: 22-12629     Document: 27-1     Date Filed: 04/27/2023   Page: 1 of 6

                                                   [DO NOT PUBLISH]
                                    In the
                United States Court of Appeals
                         For the Eleventh Circuit

                           ____________________

                                 No. 22-12629
                           Non-Argument Calendar
                           ____________________

       H. GLENN ZIEGENFUSS,
       for the Estate of Margaret Ziegenfuss,
                                                      Plaintiff-Appellant,
       versus
       SECRETARY OF HEALTH AND HUMAN SERVICES,

                                                    Defendant-Appellee.

                           ____________________

                 Appeal from the United States District Court
                      for the Middle District of Florida
                  D.C. Docket No. 8:19-cv-02373-SDM-CPT
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       2                      Opinion of the Court                22-12629

                            ____________________

       Before ROSENBAUM, JILL PRYOR, and TJOFLAT, Circuit Judges.
       PER CURIAM:
              H. Glenn Ziegenfuss, proceeding pro se on behalf of his
       mother’s estate, appeals the District Court for the Middle District
       of Florida’s order granting summary judgment to the Secretary of
       Health and Human Services (the “Secretary”) on his claim seeking
       Medicare Part A coverage for skilled nursing services furnished to
       his now-deceased mother, Margaret Ziegenfuss, who was a Medi-
       care beneficiary. He argues that Margaret met Medicare Part A’s
       three-day inpatient-stay requirement before being transferred to a
       skilled nursing facility because Cleveland Clinic Hospital intended
       to admit his mother on December 27, 2007, rather than on Decem-
       ber 28, 2007, resulting in a stay of three days until December 30,
       2007.
              Ziegenfuss sought judicial review of the Secretary’s final de-
       cision in the District Court, as he was entitled to do. See 42 U.S.C.
       §§ 405(g), 1395ff(b). When an appeal is taken from summary judg-
       ment granted in favor of the Secretary under 42 U.S.C. § 405(g), we
       perform the same review functions as the district court without
       presuming that it was correct. McDaniel v. Harris, 639 F.2d 1386,
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       22-12629                 Opinion of the Court                             3

       1388 (5th Cir. 1981). 1 Our review of the Secretary’s decisions is
       limited to determining whether they are arbitrary, capricious, an
       abuse of discretion, not in accordance with law, or unsupported by
       substantial evidence. Fla. Med. Ctr. of Clearwater, Inc. v. Sebelius,
       614 F.3d 1276, 1280 (11th Cir. 2010). Substantial evidence is “more
       than a scintilla and is such relevant evidence as a reasonable person
       would accept as adequate to support a conclusion.” Id. (internal
       quotation marks omitted). We may not “decide the facts anew,
       reweigh the evidence, or substitute our judgment for that of the
       Secretary.” Bloodsworth v. Heckler, 703 F.2d 1233, 1239 (11th Cir.
       1983).
              Medicare Part A is a hospital insurance program under the
       Social Security Act that covers the costs of care at facilities such as
       hospitals, skilled nursing facilities, and hospice care facilities for el-
       igible people over 65 years old. See 42 U.S.C. §§ 1395c–1395i-6.
       Coverage for services provided in skilled nursing facilities extends
       to “post-hospital extended care services.” Id. § 1395d(a)(2)(A). The
       Act defines “post-hospital extended care services” to mean “ex-
       tended care services furnished an individual after transfer from a
       hospital in which he was an inpatient for not less than 3 consecutive
       days before his discharge from the hospital in connection with such
       transfer.” Id. § 1395x(i); see also 42 C.F.R. § 409.30(a)(1) (A patient

       1 Decisions of the Fifth Circuit issued on or before September 30, 1981, are
       binding precedent in the Eleventh Circuit. Bonner v. City of Prichard, 661
       F.2d 1206, 1209 (11th Cir. 1981) (en banc).
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       4                        Opinion of the Court                   22-12629

       is eligible for skilled nursing facility coverage only if he or she has
       been “hospitalized . . . for medically necessary inpatient hospital or
       inpatient [critical access hospital] care, for at least 3 consecutive cal-
       endar days, not counting the date of discharge.”) (originally en-
       acted in 42 C.F.R. § 405.120(c), see 31 Fed. Reg. 10,116, 10,119 (July
       27, 1966)). The Act does not define “inpatient.”
               The Medicare Benefit Policy Manual provides that time
       spent in observation or in the emergency room before inpatient
       admission does not count toward the three-day qualifying
       stay. CMS, Medicare Benefit Policy Manual, Publ’n 100-02, ch. 8,
       § 20.1, https://www.cms.gov/Regulations-and-Guidance/Guid-
       ance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673.
       It further states that inpatient status begins with the calendar day
       of hospital admission, but the day of discharge is not counted as a
       hospital inpatient day. Id. A practitioner’s order to admit as an
       inpatient is a “critical element” in clarifying when a patient has
       been admitted as an inpatient and is required for coverage under
       Part A. Id., ch. 1, § 10.2. The Medicare Claims Processing Manual
       provides that a patient is an inpatient “upon issuance of written
       doctor’s orders to that effect.” CMS, Medicare Claims Processing
       Manual,        Publ’n.       100-04,      ch.     3,     § 40.2.2(K),
       https://www.cms.gov/Regulations-and-Guidance/Guid-
       ance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.
       The regulations generally allow doctors to make verbal orders, but
       state that they must be dated, timed, and authenticated by an ap-
       propriate practitioner. 42 C.F.R. § 482.24(c)(2).
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       22-12629                Opinion of the Court                         5

               Interpretations in agency manuals warrant deference under
       Skidmore v. Swift & Co., 323 U.S. 134, 65 S. Ct. 161 (1944), mean-
       ing they are entitled to deference to the extent that they have the
       “power to persuade.” Moore ex rel. Moore v. Reese, 637 F.3d 1220,
       1235 n.26 (11th Cir. 2011) (internal quotation marks omitted) (ap-
       plying Skidmore deference to the CMS Medicaid Manual). Skid-
       more deference to an agency interpretation is dependent upon “the
       thoroughness evident in its consideration, the validity of its reason-
       ing, its consistency with earlier and later pronouncements, and all
       those factors which give it power to persuade, if lacking power to
       control.” Skidmore, 323 U.S. at 140, 65 S. Ct. at 164.
              Here, Ziegenfuss has not shown that the Secretary’s denial
       of Medicare Part A coverage on the basis that Margaret did not
       meet the qualifying three-day inpatient-stay requirement before
       being transferred to the skilled nursing facility was arbitrary, capri-
       cious, an abuse of discretion, contrary to the Social Security Act, or
       unsupported by substantial evidence. Since Margaret was dis-
       charged on December 30th, which is not included in the three-day
       calculation, she needed to be admitted on December 27th or earlier
       to have a qualifying three-day stay. But substantial evidence sup-
       ported the finding that Margaret only stayed at the hospital for two
       days—from December 28, 2007, to December 30, 2007. All medical
       records showed that she was admitted on December 28th and dis-
       charged on December 30th. The admissions order was signed on
       the 28th, the transfer order listed admission and discharge dates of
       12/28/07 and 12/30/07, and summary records and medication
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       6                      Opinion of the Court                22-12629

       administration reports listed the admission date as December 28th
       with the length of stay as two days. There was no documentation
       in the record of a physician’s verbal order to admit Margaret to the
       hospital on December 27th to support a finding that she was admit-
       ted on that date. Accordingly, we affirm.
             AFFIRMED.