My grandmother had her TAVR and unplanned pacemaker insertion on June 9. She was discharged from the hospital late in the day on June 10. Was doing OK at home until she developed 101.7° temperature four days postop on a Friday evening. We tried to reach her cardiologist and got no reply from the answering service. The home health PT happened to be at the house and she recommended. I take her to the hospital. The home health RN on call was also contacted and she recommended the same. I took her to the hospital an hour away that did the procedure, and after 18 hours in the ER, they kept her and she was released late in the day on Monday, June 15. We arrived in the ER around 9 PM Friday evening. Also of note is when she was put back in the hospital, they realize that she should’ve been sent home from the initial procedures with oral antibiotics. She was not. So they made a mistake. The hospital has assigned this as being on observation status, so of course her Medicare advantage plan is not wanting to pay. We plan to fight this. None of the medical professionals we consulted recommended that we’d stayed at home. When she got admitted, they did blood cultures, urine cultures, a chest, x-ray, a CTA scan, and Doppler studies of her very painful left arm, which is the same side as the pacemaker. Saturday afternoon, the cardiology team NP came by and said she was definitely being admitted, because they wanted to await the results of the blood cultures and also do an echo. And of course, adding to the mystery is that her temperature was normal by the time I got her to the hospital, stayed normal during her stay,, and reappeared after she returned home from the re admission. So she is still now being evaluated outpatient with another echo and bloodwork this week.
So her rejection letter from Medicare states that she did not need to be admitted because she did not have an infection. Well, we were awaiting the results of the blood cultures to find out if she had an infection. Anyway, I’m in the process of researching how to appeal this. Apparently, she was also in the hospital for two midnights so that alone should qualify her for payment for a Medicare. Does anyone have any words of wisdom on how to do all this?
You actually have several strong arguments, and I would focus less on whether she ultimately had an infection and more on whether the physicians reasonably believed she required hospital-level care while they ruled out a potentially serious postoperative complication.
A few important points:
The Two-Midnight Rule is often misunderstood.
It is a Medicare payment guideline, not an automatic entitlement.
Simply staying through two midnights does not guarantee inpatient status.
However, if the physicians expected she would need hospital care crossing two midnights while evaluating a potentially serious condition, that supports inpatient admission.
The strongest facts in your case are:
She was only days post-TAVR and pacemaker implantation.
She developed a documented fever of 101.7°F after a major cardiac procedure.
Multiple medical professionals (PT, home health RN, cardiology answering service attempt) agreed she needed emergency evaluation.
She required extensive testing including blood cultures, urine cultures, CTA, chest X-ray, Doppler studies, echocardiography, and specialist cardiology management.
Cardiology specifically stated they were awaiting blood culture results and echocardiogram findings before determining whether a serious postoperative infection or device-related complication existed.
The hospital acknowledged she should have been discharged after the original procedure with oral antibiotics but was not.
Her symptoms recurred after discharge, further supporting that this was not a trivial issue.
Ask for the physician's admission documentation. The most important document may be the cardiologist's or hospitalist's note stating:
why admission was necessary,
concern for infection,
concern for endocarditis,
concern for pacemaker infection,
concern for postoperative complication,
need to await blood culture results.
If that language is in the chart, it can be very persuasive.
RE: Request for Reconsideration of Denial of Inpatient Hospital Coverage
Patient: [Grandmother's Name]
Member ID: [ID Number]
Dates of Service: June 12–15, 2026
To Whom It May Concern,
I am requesting reconsideration of the denial of coverage for my grandmother's hospitalization from June 12 through June 15, 2026.
The denial states that inpatient admission was not medically necessary because she ultimately was not found to have an infection. This conclusion overlooks the clinical circumstances that existed at the time physicians made the decision to admit her.
My grandmother had undergone a TAVR procedure and unplanned pacemaker implantation on June 9 and was discharged on June 10. Four days later she developed a fever of 101.7°F. Given her recent cardiac procedures and implanted cardiac device, this raised immediate concern for a potentially serious postoperative complication, including bloodstream infection, endocarditis, device infection, or other procedure-related complications.
Multiple healthcare professionals independently advised that she required emergency evaluation. These included her home health physical therapist and the on-call home health nurse. Attempts were made to contact her cardiology team, but no response was received.
Upon arrival at the hospital, physicians initiated an extensive diagnostic evaluation, including blood cultures, urine cultures, chest imaging, CT angiography, Doppler studies of a painful arm on the side of the pacemaker implantation, and later echocardiographic evaluation. The cardiology team informed us that she was being admitted because they needed to await blood culture results and perform further cardiac evaluation before determining whether a serious infection or complication was present.
Importantly, medical necessity should be evaluated based on the patient's condition and the physician's clinical judgment at the time of admission—not solely on the final diagnosis. The fact that a serious infection was ultimately not confirmed does not mean that hospitalization was unnecessary while potentially life-threatening complications were being investigated.
Additionally, during this hospitalization the care team informed us that she should have been discharged after her initial procedure with oral antibiotics but was not. This omission further increased concern for postoperative infection and supported the need for close hospital monitoring.
Given her recent TAVR, recent pacemaker implantation, documented postoperative fever, specialist cardiology involvement, need for blood culture monitoring, advanced imaging, and continued outpatient evaluation after discharge, the decision to admit her was medically reasonable and necessary.
I respectfully request that the denial be overturned and that coverage be approved for this hospitalization.
Sincerely,
[Name]
[Relationship to Patient]
[Phone Number]