Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for the inpatient hospital care provided on May 29, 2023. We decided that 
the Plan does not have to pay for the inpatient hospital care provided from May 30, 2023, to June 1, 2023.  
 
You asked the Plan to pay for the inpatient hospital care provided from May 29, 2023, to June 1, 2023. You say 
that the enrollee required continued medically necessary inpatient services for persistent symptoms and 
continued care. The Plan says that the enrollee was stabilized on May 30, 2023. The Plan also says that the 
hospital did not promptly notify the Plan upon stabilization of the enrollee's medical condition or request 
authorization prior to providing post-stabilization services. 
 
We decided that the Plan has to pay for the inpatient hospital care provided on May 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 item/service at issue. Our reviewer says 
that the inpatient hospital care provided on May 29, 2023, was medically necessary. Our physician reviewer 
found the provided records indicate that the enrollee was not medically stable for transport until 5:18 am on 
May 30, 2023. Therefore, the reviewer found that the inpatient hospital care provided on May 29, 2023 was 
medically reasonable or necessary. 
 
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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pay for the inpatient hospital care provided on May 29, 2023.  
 
We also decided that the Plan does not have to pay for the inpatient hospital care provided from May 30, 
2023, to June 1, 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 item/service at issue. Our reviewer says 
that the inpatient hospital care provided from May 30, 2023, to June 1, 2023, was not medically necessary. Our physician reviewer found the provided records indicate that as of 5:18 am on May 30, 2023, per the progress 
note documented by the Pulmonary/Critical Care physician it is noted the enrollee was "hemodynamically 
stable," and "oxygenating well on a nasal cannula". The enrollee stated they were "much better" and denied any 
chest pain or shortness of breath. A medical doctor (MD) order entered to transfer the enrollee to telemetry at 
1:07 pm. The provided records indicate that all inpatient care provided from May 30, 2023, to June 1, 2023, 
was not needed on an emergent basis. The provided records do not indicate that the treating physician 
documented that the enrollee was not stable for transfer on any dates of service. Therefore, the reviewer found 
that the the inpatient hospital care provided from May 30, 2023, to June 1, 2023, was not medically reasonable 
or necessary.  
 
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 item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pay for the inpatient hospital care provided from May 30, 2023, to June 1, 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.