Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued acute inpatient psychiatric hospital care 
provided from October 18, 2022, through October 19, 2022. 
 
You asked the Plan to pay for these services. You say that the acute inpatient psychiatric hospital care provided 
was medically necessary for the enrollee. 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 these services. Our reviewer says that the 
continued acute inpatient psychiatric hospital care provided was not medically necessary. Our physician 
reviewer found that the enrollee was involuntarily admitted for an acute inpatient psychiatric hospitalization on 
October 5, 2022 with Major Neurocognitive Disorder with Behavioral Disturbance. 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 
date 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 beyond the date 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 beyond the date in 
question as she was not a danger to herself or others and did not have auditory or visual hallucinations. 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 enrollees condition or were for the purpose of a diagnosis beyond the 
date in question. 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 the criteria for coverage of the acute inpatient 
psychiatric hospital care provided from October 18, 2022 forward as this enrollee was not shown to be a danger 
to herself or others, did not have delusions, and auditory or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the continued acute inpatient psychiatric hospital care provided from October 18, 2022, through  
October 19, 2022.