Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from October 25, 2022, 
through October 27, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary. 
 
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 these services. 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 was admitted to the health care facility at an inpatient level of care status on October 25, 
2022 from the emergency room. The enrollees symptom complex presentation included the diagnoses of 
Asthma, Deep Vein Thrombosis and Pulmonary Embolus, Chronic Obstructive Pulmonary Disease, 
Gastroesophageal Reflux Disease, Hyperlipidemia, Hypertension, Diabetes Mellitus, and an asymptomatic 
urinary tract infection among other clinical issues. The enrollees chief complaint included falling over while 
she was picking up something on the floor. It is unclear if she suffered a loss of conscientiousness. The enrollee 
was admitted, examined, evaluated, and treated for the active issues at hand in the usual and customary manner. 
The enrollees physical examination was interpreted to indicate that she was in no acute distress and her heart 
was interpreted to indicate a normal rhythm, and rate. Neurologically the enrollee was alert and oriented to 
person, time, and place. The urinalysis was suspected to be abnormal, and a computed tomography (CT) scan 
of the chest was normal as was a CT scan of the enrollees spine. A chest film was interpreted to indicate no 
pathology. The enrollee was treated symptomatically and was deemed to be stable enough to be discharged on 
October 27, 2022. The review has determined that the record showed that at the time of the inpatient admission 
the admitting physician reasonably expected that the enrollees necessary hospital care (including earlier 
emergency department (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 these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from October 25, 2022, through October 27, 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.