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 
September 27, 2022, through November 9, 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 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 August 23, 2022 with Dementia 
and Schizophrenia. 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. The 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 did not meet the criteria for 
coverage of the acute inpatient psychiatric hospital care provided from September 27, 2022 forward as she 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 September 27, 2022, through 
November 9, 2022.