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 
January 21, 2023, through February 20, 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 January 21, 2023, through February 20, 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 January 12, 2023 with Major Neurocognitive 
Disorder, Unspecified with Behavioral Disturbance. 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 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. 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 
January 21, 2023 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 as she awaited 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 January 21, 2023, through February 20, 2023.