Hultzman v. Weinberger

Dora Hultzman (plaintiff) spent 59 days undergoing inpatient treatment at Albert Einstein Medical Center (AEMC) on the order of her physician, Dr. Kravitz. Hultzman, aged 73, suffered from severe rheumatoid arthritis and was nonambulatory. Dr. Kravitz had previously treated Hultzman’s arthritis at the Moss Rehabilitation Center; however, because Hultzman developed urinary issues, anemia, and gastrointestinal bleeding, Dr. Kravitz believed it was medically necessary to treat Hultzman at AEMC as an inpatient to address her medical issues comprehensively. During Hultzman’s stay, both Dr. Kravitz and AEMC’s utilization review committee repeatedly certified that her continued inpatient care was medically necessary. After Hultzman was discharged, AEMC submitted a payment request to Blue Cross of Greater Philadelphia (Blue Cross), Medicare’s local fiscal intermediary. Blue Cross denied the claim, finding that Hultzman could have been treated in a lesser facility and that her extended stay at AEMC was an overutilization of inpatient services. Caspar Weinberger (secretary) (defendant), the secretary for the Department of Health and Human Services, conceded that the services Hultzman received at AEMC were necessary to treat her myriad medical conditions but affirmed Blue Cross’s decision that inpatient admission for those services was unnecessary. Both Blue Cross and the secretary agreed that Hultzman’s inpatient stay was not for custodial care. On appeal, the district court affirmed the secretary’s decision. Hultzman appealed.