Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services from March 15, 2022, to March 20, 2022. We decided that 
the Plan does not have to pay for the services from March 21, 2022, to April 6, 2022.  
 
You asked the Plan to pay for acute inpatient hospital services provided to the enrollee from March 15, 2022, to 
April 6, 2022. You say that this was medically necessary. The Plan says that when post-stabilization care is 
obtained from a non-contract provider, approval is required. 
 
We decided that the Plan has to pay for the services from March 15, 2022, to March 20, 2022.  
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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. Our reviewer says that the enrollee is a male who 
presented to the hospital following recent fall injuring multiple body areas. Fentanyl was positive in urine. 
Following initial work-up, he quickly was diagnosed with rhabdomyolysis with acute renal failure requiring 
emergent hemodialysis. There was no specific documentation from the treating physician that the patient was 
stable on a particular day during the hospital stay, however, the documentation of the clinical course detailed 
that the patient started to experience improvement in kidney function on 3/21/22 and would have been stable 
for transfer to a participating hospital via ambulance on that date.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
the services from March 15, 2022, to March 20, 2022.  
 
We also decided that the Plan does not have to pay for the services from March 21, 2022, to April 6, 
2022. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 the services from March 21, 2022, to April 
6, 2022. Our reviewer says that as there was an improvement in kidney function on 3/21/22, the enrollee would 
have been stable to transfer on this date. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services from March 21, 2022, to April 6, 2022 have not been met. 
Therefore, we decided that the Plan does not have to pay for the services from March 21, 2022, to April 6, 
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.