Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for the inpatient care provided until April 6, 2023, at 1:18 pm. We decided 
that the Plan does not have to pay for the inpatient care provided from April 6, 2023, at 1:19 pm, to April 9, 
2023.  
 
You asked the Plan to pay for the inpatient hospital care provided from April 5, 2023, to April 9, 2023. You say 
that the post-stabilization care was authorized. You say that additional reimbursement should be made. The 
Plan says that inpatient care at the out-of-network facility was not medically necessary to stabilize the enrollee. 
 
We decided that the Plan has to pay for the inpatient care provided until April 6, 2023, at 1:18 pm.  
 
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 care provided on April 6, 2023, until 1:18 pm was medically necessary. Our physician 
reviewer found there is no specific documentation by the treating physician regarding stability for transfer. The 
reviewer also found that based on the clinical documentation available in the medical record, the patient was 
stable for transfer on April 6, 2023, at 1:18 pm. Therefore, the reviewer found that the inpatient care provided 
until April 6, 2023, at 1:18 pm 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 inpatient care at issue have been met. Therefore, we decided that the Plan 
has to pay for the inpatient care provided until April 6, 2023, at 1:18 pm.  
 
We also decided that the Plan does not have to pay for the inpatient care provided from April 6, 2023, at 
1:19 pm, to April 9, 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 care provided from April 6, 2023, at 1:19 pm, to April 9, 2023, was not medically necessary. 
Our physician reviewer found there is no specific documentation by the treating physician regarding stability 
for transfer. The reviewer also found that based on the clinical documentation available in the medical record, the patient was stable for transfer as of April 6, 2023, at 1:18 pm. Therefore, the reviewer found that the 
inpatient care provided from April 6, 2023, at 1:19 pm, to April 9, 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 care provided from April 6, 2023, at 1:19 pm, to April 9, 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.