Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient behavioral health services provided from  
January 17, 2023, to January 30, 2023.  
 
You asked the Plan to pay for the inpatient behavioral health services. You say that the inpatient behavioral 
health services were medically necessary. The Plan denied your request. The Plan says the inpatient behavioral 
health services were not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 inpatient behavioral health services. Our 
reviewer says that the requested inpatient behavioral health services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that based upon review of the records provided it was 
not expected you would improve in a reasonable period of time beyond the dates in question as you were not showing any dangerousness to self or others, auditory or visual hallucinations and 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 you 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. 
You did not require inpatient mental health treatment beyond the dates in question as noted above as you were 
not a danger to yourself or others and did not have any delusions, 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 for 
the dates in question were reasonably expected or medically necessary to improve your condition or for the 
purpose of diagnosis. You were treated under an individualized treatment plan found in the record. It appears 
that the services were supervised and evaluated by a physician. Based upon review the records provided, you 
do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question 
of January 17, 2023, forward and could have been treated in a lesser restrictive setting as you were not showing 
any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any 
behaviors or aggression being cooperative and compliant while not showing any acute 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 the inpatient behavioral health services  have not been met. Therefore, we 
decided that the Plan does not have to pay for inpatient behavioral health services provided from  
January 17, 2023, to January 30, 2023.