Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric care provided from December 10, 2021, 
to February 16, 2022. 
 
You asked the Plan to pay for the inpatient psychiatric care. You say that this entire admission was medically 
necessary. The Plan denied your request. The Plan says the patient was admitted for inpatient psychiatric care from November 18, 2021, to February 16, 2022. The patient was admitted because the patient had thoughts of 
wanting to harm himself and others and was unable to care for himself. On December 8, 2021, the patient was 
decreased to a low risk in the psychiatric unit and no longer had a wish to harm himself or others. The Plan 
contends that as of December 10, 2021, the patient no longer required inpatient psychiatric care and could have 
been managed at a lower level 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 inpatient psychiatric care was not medically necessary from December 10, 2021, to February 16, 
2022. Our physician reviewer found that this 43-year-old male was admitted to the acute inpatient psychiatric 
hospitalization on November 18, 2021, with Cognitive Disorder, Not Otherwise Specified, Mood Disorder Due 
to Traumatic Head Injury and Narcissistic Personality Disorder. Based upon review the records provided it was 
not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was 
not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive 
behaviors while not showing any acute threats of 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 
dates in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or 
abnormal behaviors. The health plans denial of continued inpatient psychiatric services appears appropriate. 
This enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as 
he was not a danger to himself or others and did not have any delusions, 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 
for the dates in question were reasonably expected or medically necessary to improve the patients condition or 
for the purpose of diagnosis. This patient was treated under an individualized treatment plan found in the 
record. It appears that the services were supervised and evaluated by a physician. Based upon review the 
records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health 
treatment beyond the date in question of December 10, 2021, forward and could have been treated in a lesser 
restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, 
delusions and was not showing any behaviors or aggression being cooperative and compliant while not 
showing any acute threats to safety as he awaited placement. 
 
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 December 10, 2021, to February 16, 
2022.