Appeal type: unknown
Decision: unknown

If the patient requires medically necessary hospital care that is expected to span 2 or more midnights, then inpatient admission is generally appropriate. "Span 2 or more midnights" includes time spent in the ED and/or observation, as well as time spent at another hospital prior to transfer to the current facility.
 
If the physician expects the patient's medically necessary treatment to span less than 2 midnights and NOT involve services designated by CMS as inpatient-only, it is generally appropriate to treat tThe rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that an inpatient admission is generally appropriate when the admitting physician expects the patient to need hospital care that crosses at least two midnights. The expectation should be based on such complex medical factors as medical history, the severity of signs and symptoms, current medical needs, and medical risk. The factors must be documented in the medical record. If an unforeseen event, such as a patient's death or transfer, results in a shorter stay, the patient may be considered to be treated as an inpatient. An inpatient admission for a surgical procedure listed by Medicare as "inpatient only" is generally appropriate, regardless of the length of stay. An inpatient admission may be appropriate if the admitting physician expects a patient to require hospital care for only a limited period of time. The decision to admit as an inpatient must be based on the clinical judgment of the physician and must be supported by the medical record. You can find this rule at 42 CFR Section 412.3.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.he patient in outpatient status.

The decision to admit as an inpatient should generally be based on the treating physician's reasonable expectation of a length of stay spanning 2 or more midnights, taking into account complex medical factors that must be documented in the medical record.  Because this is based upon the physician's expectation, as opposed to a retroactive determination based on the actual length of stay, unforeseen circumstances that result in a shorter stay than the physician's reasonable expectation may still result in a hospitalization that is appropriately considered inpatient. 

If the physician is uncertain whether the patient will be able to be discharged after 1 midnight in the hospital or whether the patient will require a second midnight of care, the initial day should be spent in observation until it is clearly expected that a second midnight would be required, at which time the physician may order inpatient admission. 

In some situations, a stay of less than 2 midnights would be appropriate for inpatient care:
--When the surgery/procedure to be provided is on the Medicare "inpatient only" list;
--When there is clear physician documentation in the medical record supporting the physician's order and expectation that the patient required care spanning at least 2 midnights even though that did not ultimately transpire due to the death of the patient, transfer to a different facility to receive needed care, departure against medical advice, unanticipated recovery, or election of hospice care;
--When the care involves new onset mechanical ventilation; or
--When there are "rare and unusual" circumstances regarding the care which are well-documented in the medical records [note: the guidance says only that these cases will be reviewed on a case by case basis].