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 
May 24, 2023, through May 26, 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 acute inpatient psychiatric services may be covered if 
the patient meets the indicated criteria.  
 
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 May 24, 2023, through May 26, 2023. 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 May 16, 2023 with Bipolar Disorder, Current 
Episode Mixed, Severe with Psychotic Features and Mild 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, or auditory and 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 dates in question as 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 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 enrollee's 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 the criteria for coverage of the acute inpatient psychiatric 
hospital care provided from May 24, 2023 forward as the enrollee was not shown to be a danger to herself or 
others. She 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 as she waited placement. 
 
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 May 24, 2023, through May 26, 2023.