Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from May 28, 2021, to May 
30, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says that it was not 
medically necessary for the enrollee to receive acute inpatient services on the dates in question. The review has 
determined that the services provided were outpatient services, not inpatient care. 
 
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 the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the enrollee with a history of recent treatment for urinary tract infection (UTI), presented to 
the emergency department (ED) on May 28, 2021, with complaints of abdominal pain, nausea, and vomiting. 
After ED treatment with Magnesium Sulfate, Rocephin, Zofran, and IVF's, the enrollee felt better, but 
continued to complain of nausea. The plan was for observation admission. She was placed in observation on 
May 28, 2021, for UTI, nausea, and vomiting. Additionally, she complained of right ear pain and was 
diagnosed with acute otitis media. On May 29, 2021, she continued to complain of abdominal pain and 
inability to keep anything down. Labs were unremarkable and vital signs improved. Gastrointestinal consulted 
on May 29, 2021, and noted the enrollee felt better with minimal nausea, and no vomiting. The enrollee was 
initiated on proton pump inhibitor (PPI) for suspected gastritis versus gastroesophageal reflux disease (GERD). 
Her symptoms resolved and she discharged home on May 30, 2021, with planned outpatient follow up. This 
review has determined that the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) 
would span two 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from May 28, 2021, to May 30, 2021.  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.