Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.The rules say that Discharge Criteria (Intensity of Service):Patients in inpatient psychiatric care may be discharged to a less intensive level of outpatient care. A less intensive level of service would be considered when patients no longer require 24-hour observation for safety, diagnostic evaluation, or treatment as described above. These patients would become outpatients, receiving either psychiatric partial hospitalization or individual outpatient mental health services, rendered and billed by appropriate providers.Discharge Criteria (Severity of Illness):Patients whose clinical condition improves or stabilizes, who no longer pose an impending threat to self or others, and who do not require 24-hour observation available in an inpatient psychiatric unit should be discharged to outpatient care. In addition, patients who are persistently unwilling or unable to participate in active treatment of their psychiatric condition, would also be appropriate for discharge.The following services do not represent reasonable and medically necessary inpatient psychiatric services and coverage is excluded under Title XVIII of the Social Security Act, Section 1862(a)(1)(A):-Services which are primarily social, recreational or diversion activities, or custodial or respite care;-Services attempting to maintain psychiatric wellness for the chronically mentally ill;-Treatment of chronic conditions without acute exacerbation or the ability to improve functioning;-Vocational training; -Medical records that fail to document the required level of physician supervision andtreatment planning process;-Electrosleep therapy (CMS Publication 100-03, Chapter 1, Section 30.4);-Electrical Aversion Therapy for treatment of alcoholism (CMS Publication 100-03, Chapter 1, Section 130.4);-Hemodialysis for the treatment of schizophrenia (CMS Publication 100-03, Chapter 1, Section 130.8);-Transcendental Meditation (CMS Publication 100-03, Chapter 1, Section 30.5);-Multiple Electroconvulsive Therapy (MECT) (CMS Publication 100-03, Chapter 1, Section 160.25).
It is not reasonable and medically necessary to provide inpatient psychiatric hospital services to the following types of patients, and coverage is excluded under Title XVIII of the Social Security Act, Section 1862(a)(1)(A):-Patients who require primarily social, custodial, recreational, or respite care;-Patients whose clinical acuity requires less than twenty-four (24) hours of supervised care per day;-Patients who have met the criteria for discharge from inpatient hospitalization (i.e., patients waiting for placement in another facility);-Patients whose symptoms are the result of a medical condition that requires a medical/surgical setting for appropriate treatment;-Patients whose primary problem is a physical health problem without a concurrent major psychiatric episode. The treatable psychiatric symptoms/problem(s) must exceed any medical problems for the patient to be placed in an inpatient psychiatric unit;-Patients with alcohol or substance abuse problems who do not have a combined need for "active treatment" and psychiatric care that can only be provided in the inpatient hospital setting. (CMS Publication 100-03, Chapter 1, Section 130.1 and 130.6, respectively);-Patients for whom admission to a psychiatric hospital is being used as an alternative to incarceration (i.e., court ordered admission not meeting medical necessity criteria);-Patients admitted by a court order or whose admission is based on protocol and do not meet admission criteria (i.e., admissions based on hospital, legal, local,or state protocols do not preclude the patient from meeting the medical necessity for admission to an inpatient psychiatric hospital).You can find this information in Medicare's Local Coverage Determination (LCD): Psychiatric Inpatient Hospitalization (L33975).If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.