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 19, 2022, through December 24, 2022. 
 
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 for all symptom sets or diagnoses, the severity and 
acuity of symptoms and the likelihood of response to treatment, combined with the requirement for an 
intensive, 24-hour level of care, are the significant factors in determining the necessity of inpatient psychiatric 
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 19, 2022, through December 24, 2022. Our reviewer says that the acute inpatient 
psychiatric hospital care provided was not medically necessary. Our physician reviewer found that the enrollee 
was involuntarily admitted for acute inpatient psychiatric hospitalization on December 7, 2022 with Bipolar 
Disorder, Currently Manic with Psychotic Features, to rule out Schizoaffective Disorder Bipolar Type. Based 
upon the review of the records provided, it was not expected that 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, did not 
have auditory or visual hallucinations, and was 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, or auditory and 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 enrollees condition or were for the purpose of a 
diagnosis. It appears that the services were supervised and evaluated by a physician. Based upon the review of 
the records provided, this enrollee does not meet the criteria for coverage of acute inpatient mental health 
treatment provided beyond the date in question of December 19, 2022 forward and could have been treated in a 
lesser restrictive setting. 
                                                                                                                              
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 acute inpatient psychiatric hospital care provided 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 19, 2022, through December 24, 2022.