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 
March 1, 2023, through March 27, 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 the acute inpatient psychiatric hospital care 
provided from March 1, 2023, through March 27, 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 February 24, 2023 with Schizophrenia Spectrum 
Disorder, Unspecified. 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, 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 did not meet the criteria for coverage of 
the acute inpatient mental health treatment provided beyond the date in question of March 1, 2023 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 March 1, 2023, through March 27, 2023.