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 December 7, 2022, through December 12, 2022. 
 You asked the Plan to pay for these services. You say that the continued acute inpatient psychiatric hospital 
care provided was medically necessary for the enrollee. The Plan denied your request. The Plan says the 
continued 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 this enrollee was involuntarily admitted for acute inpatient psychiatric hospitalization on 
December 4, 2022 with Schizophrenia Spectrum Disorder, unspecified. 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 does not meet criteria for coverage of the continued acute inpatient psychiatric hospital 
care provided from December 7, 2022 forward as this enrollee was not shown to be a danger to herself or 
others, and 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 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 December 7, 2022, 
through December 12, 2022.