Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient psychiatric services provided from February 7, 
2020, through February 19, 2020. 
 
You asked the Plan to pay for these services. You say that the inpatient psychiatric services provided were 
medically necessary for the enrollee. The Plan denied your request. The Plan says the inpatient psychiatric 
services provided were not medically necessary. Additionally, the services were not prior authorized.  
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 
inpatient psychiatric services provided were not medically necessary.  
 
 
 
 
Our physician reviewer found that the patient was admitted for acute inpatient psychiatric hospitalization on 
February 6, 2020 with Schizophrenia, Major Depressive Disorder, History of Stimulant Use, History of 
Cannabis Use and History of Alcohol Use. Based upon review of the records provided, it was not expected this 
enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or 
homicidal ideation noted and no auditory or visual hallucinations. She was noted to be preoccupied. It did not 
appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care 
rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or 
others but was compliant with her treatment. The health plan?s denial of continued inpatient psychiatric 
services is appropriate. This enrollee did not appear to require inpatient mental health treatment beyond the 
date in question as she was not a danger to herself or others, no auditory or visual hallucinations while being 
cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. 
It did not appear that the services were reasonably expected to improve the patient?s condition or were for the 
purpose of diagnosis beyond the date in question. This patient was treated under an individualized treatment 
plan found in the record. It did appear that the records were supervised and evaluated by a physician. Based 
upon review of the records provided, the admission of this patient does not meet the criteria for continued acute 
inpatient mental health treatment for the dates in question of February 7, 2020 forward as this patient was not 
shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was 
cooperative/compliant with treatment. 
 
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 psychiatric services have not been met. Therefore, we decided that 
the Plan does not have to pay for the inpatient psychiatric services provided from February 7, 2020, through 
February 19, 2020.