Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued acute inpatient psychiatric hospital care 
provided from November 18, 2022, through November 30, 2022. 
 
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 these services. 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 the acute inpatient psychiatric hospitalization on November 15, 2022 with 
Schizoaffective Disorder, Unspecified Type. 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, auditory or 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 dates 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 dates 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 dates in question. It did appear that the 
records 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 psychiatric hospital care provided from 
November 18, 2022 forward as this enrollee was not shown to be a danger to herself or others, did not have 
delusions, or auditory and visual hallucinations as noted. She was cooperative/compliant with treatment while 
not showing any threats the safety. It was appropriate for this enrollee to be hospitalized from November 15, 
2022 until November 17, 2022 as she was a danger to herself or others and was showing psychosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the continued acute inpatient psychiatric hospital care provided from November 18, 2022, 
through November 30, 2022.