Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for the inpatient hospital services provided on February 21, 2023, to 
March 29, 2023. We decided that the Plan does not have to pay for the inpatient hospital services provided on 
March 30, 2023, to May 17, 2023.  
 
You asked the Plan to pay for inpatient hospital services provided on February 21, 2023, to May 17, 2023. You 
say that the records provided support that the inpatient services in dispute were medically necessary. The Plan 
says that the prior authorization has insufficient units remaining. 
 
We decided that the Plan has to pay for the inpatient hospital services provided on February 21, 2023, to 
March 29, 2023.  
 
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 inpatient hospital services. Our reviewer 
says that the criteria for coverage of inpatient care with an out-of-network (OON) provider have been met for 
dates of service February 21, 2023, to March 29, 2023. Our physician reviewer found as of March 30, 2023, the 
enrollee was hemodynamically stable and appropriate for ambulance transport to a Plan facility for admission 
level of care services. Her sepsis had resolved with intravenous (IV) antibiotics, and she had been evaluated by 
psychiatry. The enrollee was stable on her medical regimen. Post-stabilization care services at the non-plan 
hospital were not medically necessary for dates of service March 30, 2023, to May 17, 2023.   
 
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 inpatient hospital services provided on February 21, 2023, to March 29, 
2023, have been met. Therefore, we decided that the Plan has to pay for the inpatient hospital services provided 
on February 21, 2023, to March 29, 2023.  
 
We also decided that the Plan does not have to pay for the inpatient hospital services provided on March 
30, 2023, to May 17, 2023. 
 
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 inpatient hospital services provided on 
March 30, 2023, to May 17, 2023. Our reviewer says that the criteria for coverage of inpatient care with an out-
of-network (OON) provider have been met for dates of service February 21, 2023, to March 29, 2023. Our 
physician reviewer found as of March 30, 2023, the enrollee was hemodynamically stable and appropriate for 
ambulance transport to a Plan facility for admission level of care services. Her sepsis had resolved with 
intravenous (IV) antibiotics, and she had been evaluated by psychiatry. The enrollee was stable on her medical 
regimen. Post-stabilization care services at the non-plan hospital were not medically necessary for dates of 
service March 30, 2023, to May 17, 2023.   
 
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 inpatient hospital services provided on March 30, 2023, to May 17, 2023, 
have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services 
provided on March 30, 2023, to May 17, 2023. 
 
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.