Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient psychiatric hospital care provided from  
December 31, 2022, through January 3, 2023. 
 
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 that 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 December 31, 2022, through January 3, 2023. Our reviewer says that the acute inpatient 
psychiatric hospital care provided was medically necessary. Our physician reviewer found that the enrollee was 
admitted for acute inpatient psychiatric hospitalization on December 20, 2022 with an Unspecified Psychosis. 
Based upon the review of the records provided, it was expected that this enrollee would improve in a 
reasonable period of time for the dates in question as although she did not have suicidal or homicidal ideation, 
auditory or visual hallucinations, she did have adjustment over medication. The enrollee was compliant with 
treatment while not showing any acute threats to safety.  
 
It did 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 although she did not have dangerousness to 
self or others and was compliant with her treatment. The health plan's denial of continued inpatient psychiatric 
services is not appropriate. This enrollee did appear to require inpatient mental health treatment beyond the 
date in question although she was not a danger to herself or others and does not have auditory or visual 
hallucinations. It did appear that active treatment was taking place beyond the date in question. It did appear 
that the services were reasonably expected to improve the enrollee's 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 meet the criteria for coverage of 
the acute inpatient psychiatric hospital care provided from December 31, 2022 forward as she was undergoing 
active treatment. 
 
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 hospital care provided have been met. Therefore, we 
decided that the Plan has to pay for the acute inpatient psychiatric hospital care provided from December 31, 
2022, through January 3, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.