Utilization review should reconstruct the clinical story day by day. What risk required hospital care? Which services could only be delivered there? What changed after treatment? The answer can shift during one admission, so a sound decision must account for timing.
Separate admission from continued stay
An appropriate initial admission does not automatically justify every later day. Conversely, a stable set of vital signs does not by itself prove a patient was ready to leave. Review the intensity of services, the response to care, any new complication, and whether a safe alternative was available on the day in question.
Make the rationale traceable
A useful determination identifies the actual guideline or policy applied, the record facts that match or miss it, and the specific dates under review. If a denial cites InterQual, MCG, or a plan policy, name the source and version when documented. Do not substitute a generic standard for the one the decision actually used.
Honor the decision process
CMS's 2026 Medicare Advantage final rule restricts plans from reopening a previously approved inpatient admission except for obvious error or fraud. That policy underscores the importance of clear, timely decisions and complete documentation.
A defensible review connects the specific date, the clinical facts, and the actual coverage standard.
Keep the source close.
Sources reviewed September 24, 2026. Educational commentary; confirm current coverage, contract, and billing requirements for the date and setting of service.