Appeal type: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan has to pay for the inpatient hospital care provided from May 25, 2021, to May 27, 2021, at 1:38 pm. We decided that the Plan does not have to pay for the inpatient hospital care provided from 1:38 pm on May 27, 2021, to May 29, 2021.
You asked the Plan to pay for the inpatient hospital care provided from May 25, 2021, to May 29, 2021. You say that the inpatient hospital services were medically necessary. The Plan denied your request. The Plan says authorization was not obtained before the post stabilization care was rendered. The Plan also says that inpatient care at a non-Plan facility was not medically necessary to stabilize the enrollee.
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 decided that the Plan has to pay for the inpatient hospital care provided from May 25, 2021, to May 27, 2021, at 1:38 pm.
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 provided from May 25, 2021, to May 29, 2021. Our reviewer says that the inpatient hospital care provided from May 25, 2021, to May 26, 2021, was medically necessary. The reviewer found that the documentation provide indicates that the enrollee was not stable for transfer by ambulance to an in-network hospital until May 27, 2021, at 1:38 pm.
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 provided from May 25, 2021, to May 27, 2021, at 1:38 pm, have been met. Specifically, the enrollee was not stable for transfer by ambulance to an in-network hospital until May 27, 2021, at 1:38 pm. Therefore, we decided that the Plan has to pay for the inpatient hospital care provided from May 25, 2021, to May 27, 2021, at 1:38 pm.
We also decided that the Plan does not have to pay for the inpatient hospital care provided from 1:38pm on May 27, 2021, to May 29, 2021.
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 provided from May 25, 2021, to May 29, 2021. Our reviewer says that the inpatient hospital care provided from 1:38 pm on May 27, 2021, to May 29, 2021, was not medically necessary. Our physician reviewer found the record shows the treating physician did not document that the enrollee was not stable for transfer on any dates of service. The reviewer also found that based on the provided documentation, the enrollee was stable to transfer by ambulance to an in-network hospital on May 27, 2021, at 1:38 pm. 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 provided from 1:38 pm on May 27, 2021, to May 29, 2021, have not been met. Specifically, the file shows that the enrollee was stable and could have been moved to an in-network facility as of 1:38 pm on May 27, 2021. The file also shows that no authorization was obtained before the post stabilization care was rendered. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided from 1:38 pm on May 27, 2021, to May 29, 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.