Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care provided from 
December 22, 2022, through January 11, 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 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 
acute inpatient psychiatric hospital care provided was not medically necessary. Our physician reviewer found 
that the enrollee was admitted for acute inpatient psychiatric hospitalization on December 14, 2022 with 
Bipolar Disorder Type I, Current Episode Depressed, Severe without psychotic features, an Unspecified 
Anxiety Disorder and an Unspecified Cognitive Impairment. 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 dates 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. This 
enrollee was treated under an individualized treatment plan found in the record. 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 acute inpatient psychiatric hospital care provided from December 22, 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/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 acute inpatient psychiatric hospital care provided from December 22, 2022, through  
January 11, 2023.