Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric care provided from April 16, 2022, to 
April 27, 2022. 
 
You asked the Plan to pay for the inpatient psychiatric care. You say that the patient met criteria for inpatient 
psychiatric care because they were admitted on an involuntary commitment due to psychosis and agitation The Plan denied your request. The Plan says the inpatient psychiatric admission was not medically necessary. At 
the time of admission, the patient was not reporting suicidal or homicidal ideations nor responding to command 
auditory hallucinations. There were no medical issues that necessitated an acute inpatient level of care and the 
patient could have been managed in a less restrictive setting. 
 
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 inpatient psychiatric care. Our reviewer 
says that the inpatient psychiatric care was not medically necessary. Our physician reviewer found This 67-
year-old female was admitted to the acute inpatient psychiatric hospitalization on April 16, 2022, with Bipolar 
Disorder with Psychotic Features. 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, auditory or visual hallucinations. The patient 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 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 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. It did not appear that the services were reasonably expected to improve the 
patients condition or for the purpose of diagnosis beyond the date in question. Our physician review was 
unable to find an individualized treatment plan however the entire record is not present. It did appear that the 
records were supervised and evaluated by a physician. Based upon review the records provided for the 
admission of this patient does not meet the criteria for April 16, 2022-forward as this patient was not shown to 
be a danger to herself or others, delusions, auditory or visual hallucinations noted. She was 
cooperative/compliant with treatment while not showing any threats the 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 inpatient psychiatric care have not been met. Therefore, we decided that the 
Plan does not have to pay for inpatient psychiatric care provided from April 16, 2022, to April 27, 2022.