## Facts

- Marianne Lewin, a 91-year-old Medicare beneficiary, fell at home and broke her wrist.
- She was treated at a hospital and kept overnight, but she did not remain an inpatient for three consecutive days.
- Several days later, after complications, Lewin was admitted to the Loeb Center, a skilled nursing facility (SNF), for slightly more than one month.
- The Loeb Center required Lewin to pay for her stay in advance, totaling about $10,000.
- Lewin was not told at the time of admission that Medicare would not cover her SNF stay; she later learned Medicare denied payment because she lacked the statutory three-day inpatient hospital stay immediately before SNF admission.
- Lewin sought administrative review of the denial.
- An Administrative Law Judge (ALJ) denied coverage because Lewin did not meet the three-day inpatient prerequisite for post-hospital SNF benefits.
- The Medicare Appeals Council denied review, making the ALJ decision the final decision of the Secretary of Health and Human Services, Donna Shalala.
- Lewin filed suit in federal district court seeking judicial review under 42 U.S.C. §§ 405(g) and 1395ff.

## Issues

1. Whether Medicare law required denial of SNF coverage because Lewin lacked a three-consecutive-day inpatient hospital stay immediately preceding her SNF admission.
2. Whether Lewin could obtain payment despite failing the three-day requirement based on her lack of knowledge at admission, including under Medicare’s limitation-on-liability provisions (42 U.S.C. § 1395pp and related provisions).
3. Whether denying SNF coverage under the three-day inpatient rule violated equal protection under the Fifth Amendment.

## Decision

- The court granted the Secretary’s motion for judgment on the pleadings and affirmed the final agency decision.
- The court held Lewin was not entitled to Medicare reimbursement for her SNF stay because she did not have the required three-day inpatient hospital stay immediately before SNF admission.
- The court rejected Lewin’s attempt to obtain payment based on lack of notice or lack of knowledge, concluding the limitation-on-liability provisions did not apply where the denial rested on failure to satisfy a basic statutory eligibility condition (the three-day inpatient prerequisite).
- The court rejected the equal-protection challenge, finding the three-day inpatient rule constitutionally valid under rational-basis review.

## Legal Principles

- Under 42 U.S.C. § 405(g), the district court reviews the Secretary’s final decision to determine whether it is supported by substantial evidence and is consistent with the statute and regulations; the court does not decide eligibility anew.
- Medicare coverage for post-hospital extended care services in an SNF requires, among other conditions, an inpatient hospital stay of at least three consecutive days immediately before SNF admission; if the prerequisite is not met, coverage is not available.
- Medicare’s limitation-on-liability provisions (including 42 U.S.C. § 1395pp) can allow payment in certain noncoverage situations tied to the character of the services or related determinations, but they do not create coverage when a claimant fails a threshold statutory eligibility requirement such as the three-day inpatient rule.
- Equal-protection challenges to social-welfare classifications in the Medicare program are evaluated under rational-basis review; a coverage condition will be upheld if it is rationally related to legitimate governmental objectives such as administrable eligibility criteria and cost control.

## Conclusion

Lewin v. Shalala affirmed the Secretary’s denial of Medicare reimbursement for Lewin’s skilled nursing facility stay because Lewin did not satisfy Medicare’s three-day inpatient hospital prerequisite for SNF coverage, and the court further held that neither lack of notice nor the limitation-on-liability provisions supplied a basis for payment and that the three-day rule did not violate equal protection.


Lewin v. Shalala, 887 F. Supp. 74 (1995)