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 
December 19, 2022, through January 6, 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 December 19, 2022, through January 6, 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 December 13, 2022 with Bipolar Disorder, 
Delusional Disorder, and Anxiety 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 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 
December 19, 2022 forward as this enrollee 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. 
 
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 December 19, 2022, through January 6, 2023.