Appeal type: Inpatient Hospital
Decision: Partially Favorable

 We decided that the Plan has to pay for inpatient hospital services provided from March 28, 2022, to March 30, 
202 . We decided that the Plan does not have to pay for inpatient hospital services provided from March 28, 
2022, to March 30, 202 .  
 
You asked the Plan to pay for inpatient hospital services provided from March 28, 2022, to March 30, 2022.  
You say that this hospitalization was medically necessary because you had blood in your stool. The Plan denied 
your request. The Plan says inpatient hospitalization was not medically necessary. 
 
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 acute inpatient hospital care. Our reviewer 
says that only some of these dates of service required an inpatient level of care. Our physician reviewer found 
the provided records indicate that you had two separate visits. The two visits were for different issues (chest 
pain, black stools), and that while you may have been having black stools during the first visit, you did not 
report this to anyone and, therefore, the providers could not have addressed this issue during the first visit. At 
the time of hospitalization on March 25, 2022, you were. It was not clear that two midnights of care would be 
required. As such, you should have been placed on an outpatient observation status. There appears to have been 
a delay in performing the esophagogastroduodenoscopy (EGD). The time spent awaiting this procedure does 
not in and of itself warrant a conversion to inpatient status under the two-midnight rule. You should have 
remained on observation status from March 25, 2022, to March 28, 2022. Following the EGD, you experienced 
symptomatic orthostasis. Additional monitoring and treatment were warranted. As such, you were eligible for 
conversion to inpatient status on March 28, 2022, following the EGD, having now required two midnights of 
care. The remainder of the stay was appropriately at the inpatient level. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care from March 28, 2022, to March 30, 2022, have 
been met.  However, we have also decided that the rules for coverage of the acute inpatient hospital care from 
March 24, 2022, to March 27, 2022, have not been met. Therefore, we decided that the Plan has to pay for 
inpatient hospital services provided from March 28, 2022, to March 30, 2022. We also decided that the Plan 
does not have to pay for inpatient hospital services provided from March 24, 2022, to March 27, 2022.  
 
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.