Hospital stays: 62% of denials overturned

Year by year

By treatment

Treatments with at least 20 decisions, most decisions first. Rates on fewer than 20 decisions aren’t shown.

Recent decisions

The most recent decisions in the data, half overturned and half upheld. Each shows the reviewer’s published findings.

1. Upheld 2026 · Medical necessity · age 31–40 Admission · Complications after surgery The physician reviewer found that a patient has requested reimbursement for inpatient hospitalization services. There is no evidence presented in the records that a hospital admission was indicated in this case. Patients routinely have their arterial access…

   The physician reviewer found that a patient has requested reimbursement for inpatient hospitalization services. There is no evidence presented in the records that a hospital admission was indicated in this case. Patients routinely have their arterial access site used for angiogram procedures and are discharged the same day. With regard to the procedure performed, these procedures are able to be completed on an outpatient basis unless the patient has significant comorbidities or there are procedural or medical issues. As none of these issues were noted in the records, there is a lack of support for the need for a hospital admission and stay for the patient. The timing of the compression device removal and the patient’s blood pressure were not factors that required further monitoring. All told, the inpatient hospitalization services provided were not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for the evaluation of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in neurological surgery and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46894

2. Overturned 2025 · Urgent care · age 31–40 Admission · Digestive system The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for emergency medical services during two separate periods of admission. The medical records provided for review do not support that the…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for emergency medical services during two separate periods of admission. The medical records provided for review do not support that the services provided during the first period of admission were emergent. According to the medical records, the patient did not have an acute abdomen, and the patient’s admission diagnosis was ventral incisional hernia without obstruction or gangrene. However, the patient did receive emergent medical services during the second period of admission. Given the patient’s immunocompromised state (on tacrolimus), the patient was at risk for rapid progression of an infection which could have become life-threatening. Therefore, the patient required immediate evaluation and broad-spectrum parenteral antibiotics with close monitoring of the patient’s clinical condition and medication adjustments. Given these findings, the patient did not receive emergency medical services at any point during his first period of admission, but the patient did receive emergency medical services during the second period of admission. Final Result: The reviewer determined that part of the services at issue were emergency care services as defined by California law. Therefore, the Health Plan’s denial should be partially overturned. Credentials/Qualifications: The reviewer is board-certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case UR25-45055

3. Overturned 2025 · Medical necessity · age 41–50 Admission · Skin The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for inpatient hospitalization services. Inpatient admission was indicated for treatment of this patient's condition. The patient presented with…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for inpatient hospitalization services. Inpatient admission was indicated for treatment of this patient's condition. The patient presented with soft tissue infection due to methicillin-resistant Staphylococcus aureus (MRSA) that did not improve with oral antibiotics. Intravenous (IV) antibiotics and further evaluation were appropriate for this infection. Guidelines from the Infectious Diseases Society of America state the following: “Hospitalization is recommended if there is concern for a deeper or necrotizing infection, for patients with poor adherence to therapy, for infection in a severely immunocompromised patient, or if outpatient treatment is failing.” According to one pair of authors, patients who do not have improvement within 24-48 hours often require admission and IV antibiotic therapy. Given these findings, inpatient hospitalization services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in internal medicine with subspecialty certification in infectious diseases and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46262

4. Overturned 2025 · Medical necessity · age 51–64 Admission · Injury The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for inpatient hospitalization. The medical literature reports that older patients discharged home with home health care generally show better…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for inpatient hospitalization. The medical literature reports that older patients discharged home with home health care generally show better functional outcomes and lower readmission and mortality rates than those discharged to extended care facilities (ECFs). One study concluded that discharge to ECFs and inpatient rehabilitation facilities appear to be an independent risk factor for hospital readmissions in older trauma patients despite controlling for injury severity and comorbidities. The authors noted, “Recognition of this risk factor may aid in the disposition planning of these patients.” Based on the records, this patient was inappropriate for discharge to a lower level of care, secondary to replacement of Foley catheter for urinary retention. The patient was also being monitored after a voiding trial. Therefore, inpatient hospitalization was indicated during that time period. Additionally, the patient was not yet appropriate for safe discharge to the most appropriate post-hospital setting, which for this patient was home with home health care. Based on the records, the patient was unable to pivot/transfer to the toilet, sit on the edge of the bed without assistance, or transfer to a wheelchair. Thus, the patient’s activity level was not acceptable until the day of discharge. Overall, the inpatient hospitalization was indicated to ensure a safe discharge to the most appropriate post-hospital setting for this patient. For these reasons, the inpatient hospitalization was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in general surgery with subspecialty certification in surgical critical care and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46237

5. Overturned 2025 · Medical necessity · age 41–50 Admission · Lungs and breathing The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for inpatient hospitalization services. Current practice guidelines for the management of community-acquired pneumonia, aspiration pneumonia…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for inpatient hospitalization services. Current practice guidelines for the management of community-acquired pneumonia, aspiration pneumonia, and seizures support hospital admission in the setting of this patient’s history. There is an increased risk of aspiration-induced lung injury described in critical care literature, and increased risks of respiratory failure and mortality seen in patients with a combination of seizures and pneumonia. In this clinical setting, given the patient’s risks of ongoing seizures and worsening respiratory failure, inpatient hospitalization services were medically necessary for the treatment of this patient to protect life, to prevent significant illness or significant disability, or to alleviate severe pain Final Result: The reviewer determined that the services at issue were medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in internal medicine with subspecialty certification in critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46204

6. Upheld 2025 · Medical necessity · age 41–50 Admission · Digestive system The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested reimbursement for inpatient hospitalization services. Inpatient care is indicated when a patient requires ongoing acute management, monitoring, or treatment…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested reimbursement for inpatient hospitalization services. Inpatient care is indicated when a patient requires ongoing acute management, monitoring, or treatment that cannot be safely provided at a lower level of care. In this case, the clinical documentation indicates that the patient’s acute condition had improved and stabilized, and there were no ongoing medical needs requiring continued inpatient hospitalization. Recommendations supported transition to a lower level of care with outpatient or home-based services. The available records do not demonstrate clinical indications necessitating continued inpatient stay during the period in question. Therefore, the inpatient hospitalization services are not medically necessary for the treatment of this patient. Final Result:The reviewer determined that the services at issue were not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications:The reviewer is board-certified in internal medicine with subspecialty certifications in gastroenterology and transplant hepatology and is actively practicing. The reviewer is knowledgeable about the proposed treatment through recent or current clinical experience treating those with the same or a similar medical condition.

   Case MN25-45582

7. Upheld 2025 · Medical necessity · age 31–40 Admission · Digestive system The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested reimbursement for inpatient hospitalization services. Inpatient admission is indicated when a patient requires a higher level of care due to clinical…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested reimbursement for inpatient hospitalization services. Inpatient admission is indicated when a patient requires a higher level of care due to clinical instability, significant comorbidities, or risk of complications that cannot be safely managed at a lower level of care. In this case, the clinical documentation does not demonstrate the presence of complications, instability, or risk factors that would necessitate inpatient hospitalization. The condition described is typically managed at a lower level of care, and there is no evidence that an inpatient setting was required for safe and effective treatment. Therefore, the inpatient hospitalization services are not medically necessary for the treatment of this patient. Final Result:The reviewer determined that the services at issue were not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications:The reviewer is board-certified in internal medicine with subspecialty certifications in gastroenterology and transplant hepatology and is actively practicing. The reviewer is knowledgeable about the proposed treatment through recent or current clinical experience treating those with the same or a similar medical condition.

   Case MN25-45558

8. Upheld 2025 · Medical necessity · age 41–50 Admission · Heart and circulation The physician reviewer found that a patient has requested authorization and coverage for inpatient admission prior to the approved biopsies. Based on the records provided, the patient has conditions, but no severe changes and no symptoms. In this circumstance…

   The physician reviewer found that a patient has requested authorization and coverage for inpatient admission prior to the approved biopsies. Based on the records provided, the patient has conditions, but no severe changes and no symptoms. In this circumstance of stable cardiac disease, it should be safe to perform low-risk non-cardiac procedures without requiring a hospital admission prior to the procedures performed. Moreover, holding anticoagulation pre-procedure is the standard of care in patients taking anticoagulation to help avoid any periprocedural bleeding complications. Additionally, managing stable chronic congestive heart failure also can be safely performed in the outpatient setting during low risk noncardiac procedures where intravenous volume load can be minimized. All told, inpatient admission prior to the approved biopsies is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in cardiovascular disease with subspecialty certification in adult congenital heart disease and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-45086

9. Overturned 2025 · Medical necessity · age 41–50 Admission · Digestive system The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for inpatient hospitalization. The submitted documentation supports the medical necessity of inpatient level of care for this patient. The…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for inpatient hospitalization. The submitted documentation supports the medical necessity of inpatient level of care for this patient. The patient had rectal bleeding and was suspected of having ischemic or infectious colitis. The patient also presented with elevated lactate levels consistent with poor perfusion. The patient appropriately underwent standard evaluation and treatment for colitis, including intravenous fluids, empiric antibiotics, and supportive care. A colonoscopy was deferred and no infection was found. However, the patient had ongoing bleeding until the night prior to the day of discharge, requiring a hospital stay beyond two-midnights. Overall, given the protracted bleeding, the unknown cause of the bleeding and colitis, as well as the elevated lactate levels on presentation, the inpatient level of care was supported for the treatment of this patient. For these reasons, the inpatient hospitalization was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in internal medicine with subspecialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-45006

10. Upheld 2025 · Medical necessity · age 21–30 Admission · Digestive system The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for immediate admission to an acute care hospital.On review of the available documentation, there is a lack of support for the…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for immediate admission to an acute care hospital.On review of the available documentation, there is a lack of support for the requested immediate admission to an acute care hospital, for either the patient’s hernia or seizures. Typically for hernias, emergent surgery is indicated with incarcerated or strangulated hernias, but otherwise a planned surgery is recommended so the patient can be appropriately prepared for surgery to minimize risk. Although the patient may meet the criteria for surgical hernia repair, the patient should be referred to an in-person visit with the provider to be appropriately evaluated and triaged. The records indicate that the patient was evaluated via telehealth, which is insufficient to assess the patient’s need for surgical intervention and/or inpatient admission. Regarding the patient’s report of seizures, the chart contains a mixture of diagnoses of both epileptic and non-epileptic seizures. The provider’s documentation reports the problem as psychogenic seizures, in which case the patient does not require inpatient admission, and ongoing management in the outpatient setting is recommended. An in-person assessment could help determine whether the patient has epileptic or non-epileptic seizures, but this does not require an inpatient admission. The patient requires an in-person assessment to obtain objective evidence such as blood work and vital signs to determine a treatment plan. Overall, the requested immediate admission to an acute care hospital is not reasonable and necessary to protect life, to prevent significant illness or significant disability, or alleviate severe pain through the diagnosis or treatment of disease, illness, or injury. In addition, the requested immediate admission to an acute care hospital is not necessary to achieve age-appropriate growth and development, and attain, maintain, or regain functional capacity. Based on the available documentation, the requested immediate admission to an acute care hospital is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in internal medicine and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN25-44988

11. Overturned 2025 · Medical necessity · age 51–64 Admission · Cancer Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for full hospital admission following laparoscopic splenectomy. Fluorodeoxyglucose (FDG)-avid lesions in a positron emission tomography (PET) scan are of the most…

    Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for full hospital admission following laparoscopic splenectomy. Fluorodeoxyglucose (FDG)-avid lesions in a positron emission tomography (PET) scan are of the most concern for malignancy, and a splenectomy is indicated for tissue diagnosis. Biopsy of the splenic lesions is usually not recommended due to risk of uncontrolled bleeding and rupture of the spleen, which can be life threatening. Further, post-splenectomy patients have a uniquely severe risk of overwhelming post-splenectomy infection (OPSI), which can occur in the immediate post-operation period, as well as a risk of internal bleeding and thromboembolism. Notably, OPSI may begin as a simple respiratory infection that rapidly progresses to hyperpyrexia, headache, shivering, jaundice, anuria, septic shock, acute respiratory distress syndrome, multiple organ dysfunction syndrome, coma, and death. Further, thromboembolism, especially porto-spleno-mesenteric venous thrombosis, represents one of the most severe complications of a splenectomy. Moreover, patients without a spleen have a 200-fold increased risk of death from septicemia compared to patients with a normally functioning spleen. Thus, a post-splenectomy patient requires close inpatient monitoring. In this case, the patient presents with FDG-avid lesions in a PET scan and a splenectomy has been recommended. Close inpatient monitoring of the patient post-splenectomy is indicated especially for this patient with an American Society of Anesthesiologist (ASA) classification of 3, and with multiple co-morbidities including hypertension. Overall, a splenectomy is a complex operation with a complex post-operation course that requires close monitoring and care that can only be provided in an inpatient setting. For these reasons, the requested full hospital admission following laparoscopic splenectomy is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in general surgery and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN25-44782

12. Upheld 2025 · Medical necessity · age 51–64 Admission · Heart and circulation Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for inpatient admission to any tertiary care center for interdisciplinary assessment and stabilization. An inpatient rehabilitation facility (IRF) provides…

    Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for inpatient admission to any tertiary care center for interdisciplinary assessment and stabilization. An inpatient rehabilitation facility (IRF) provides hospital-level care to stroke survivors who need intensive, 24-hour-a-day, interdisciplinary rehabilitation care that is provided under the direct supervision of a physician. Admission to IRFs should be limited to patients for whom significant improvement is expected within a reasonable length of time and who are likely to return to a community setting, rather than being transferred to another setting such as a skilled nursing facility or a long-term care facility. According to an expert, “Most stroke deficits will see the highest rate of recovery during the first three to six months after stroke. After six months, recovery then reaches a plateau phase without additional significant improvement.” In this case, the patient experienced a cerebrovascular accident beyond this timeline with residual deficits. Additionally, there is a lack of evidence in the records of a new stroke or other medical condition causing acute changes in the patient’s condition and functioning. Given the timing of the patient’s cerebrovascular accident, the chronic nature of the patient’s deficits, and the lack of evidence in the records of acute changes in the patient’s condition and functioning, an admission to an IRF at this stage is not expected to result in a significant improvement in the patient’s condition, according to the literature. As such, the requested inpatient admission to any tertiary care center for interdisciplinary assessment and stabilization is not necessary to prevent significant disability and alleviate severe pain through the treatment of a disease. In addition, the requested inpatient admission to any tertiary care center for interdisciplinary assessment and stabilization is not necessary to attain, maintain, or regain functional capacity. For these reasons, the requested inpatient admission to any tertiary care center for interdisciplinary assessment and stabilization is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in physical medicine and rehabilitation with subspecialty certifications in pain medicine and brain injury medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollee's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN25-44623