Appeal type: Inpatient Hospital
Decision: Partially Favorable

You asked the Plan to pay for inpatient hospital care. You say that you are appealing with medical records. The
Plan denied your request. The Plan says that the denial of payment for inpatient hospital care is correct,
because the enrollee did not meet the Plan's criteria for inpatient hospitalization.
We decided that the Plan has to pay for inpatient hospital care from May 16, 2019 to May 18, 2019.
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 inpatient hospital care. Our reviewer says
that the documentation supports that the criteria for inpatient hospital care are met for May 16, 2019 to May 18,
2019. Our physician reviewer found the enrollee was evaluated in the emergency department for
gastrointestinal bleeding. She was treated with blood transfusions and reversal agents. The enrollee was
initially admitted to the intensive care unit, rapidly stabilized, and transitioned to a floor bed on May 17, 2019.
The enrollee had recurrent episodes of hypoglycemia. Records document stabilization of blood sugar and
hemoglobin on May 18, 2019. Therefore, the record shows that at the time of inpatient admission the admitting
physician reasonable expected that the enrollee's necessary hospital 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 inpatient hospital care have been met. Therefore, we decided that the Plan has to
pay for inpatient hospital care from May 16, 2018 to May 18, 2019.
We also decided that the Plan does not have to pay for inpatient care from May 19, 2019 to May 21,
2019.
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 inpatient hospital care. Our reviewer says
that the inpatient care provided after May 18, 2019 does not meet the Medicare criteria for coverage. Our
physician reviewer found that following May 18, 2019, there were no ongoing advanced interventions or
complex medical conditions. The enrollee remained with stable vital signs and no complaints.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient hospital care from May 19, 2019 to May 21, 2019 have not been met.
Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided from May 19, 2019 to May 21, 2019.
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.