Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
November 1, 2022, through November 9, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acute inpatient psychiatric hospital care 
provided was not medically necessary. 
 
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 the acute inpatient psychiatric hospital care 
provided from November 1, 2022, through November 9, 2022. Our reviewer says that the acute inpatient 
psychiatric hospital care provided was not medically necessary. Our physician reviewer found that the enrollee 
was admitted for acute inpatient psychiatric hospitalization on October 25, 2022 with Major Neurocognitive 
Disorder, Alzheimers Type with Behavioral Disturbance and Schizophrenia. Based upon the review of the 
records provided, it was not expected that this enrollee would improve in a reasonable period of time for the 
dates in question as she did not have suicidal or homicidal ideation, auditory or visual hallucinations. The 
enrollee was compliant with treatment while not showing any acute threats to safety. 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 for the dates in question as she did not have dangerousness to self or others and was 
compliant with her treatment. The health plans denial of continued inpatient psychiatric services is 
appropriate. This enrollee did not appear to require inpatient mental health treatment for the dates in question 
as she was not a danger to herself or others and does not have auditory or visual hallucinations. It did not 
appear that active treatment was taking place for the dates in question. It did not appear that the services were 
reasonably expected to improve the enrollees condition or were for the purpose of a diagnosis. It did appear 
that the records were supervised and evaluated by a physician. Based upon the review of the records provided, 
the enrollee did not meet criteria for coverage of the acute inpatient psychiatric hospital care provided from 
November 1, 2022 forward as this enrollee was not shown to be a danger to herself or others. The enrollee did 
not have delusions, or auditory and visual hallucinations as noted. She was cooperative and compliant with 
treatment while not showing any threats to safety. 
 
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 acute inpatient psychiatric hospital care have not been met. Therefore, we 
decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
November 1, 2022, through November 9, 2022.