Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient psychiatric hospital care provided from March 1, 
2023, through March 14, 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 that 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 March 1, 2023, through March 14, 2023. Our reviewer says that the acute inpatient psychiatric 
hospital care provided was medically necessary. Our physician reviewer found that the enrollee was admitted 
for acute inpatient psychiatric hospitalization on February 23, 2023 with Schizoaffective Disorder. Based upon 
the review of the records provided, it was expected that this enrollee would improve in a reasonable period of 
time beyond the dates in question as although he was not showing any dangerousness to self or others, he did 
have auditory but no visual hallucinations and did not show aggressive behaviors or acute threats of safety. It 
did 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 although he did not have any suicidal or 
homicidal thoughts, he did have auditory but no visual hallucinations or abnormal behaviors.   
 
The health plan's denial of continued inpatient psychiatric services appears inappropriate. This enrollee did 
require inpatient mental health treatment beyond the dates in question as noted above as though he was not a 
danger to himself or others, he did have noted delusions, and auditory but no visual hallucinations. It did appear 
that active treatment was taking place beyond the date in question. It did appear that the services for the dates 
in question were reasonably expected or medically necessary to improve the enrollee's condition or were for 
the purpose of a diagnosis. It appears that the services were supervised and evaluated by a physician. Based 
upon the review of the records provided, this enrollee does meet the criteria for coverage of the acute inpatient 
mental health treatment provided beyond the date in question of March 1, 2023 forward and could not have 
been treated in a lesser restrictive setting. 
 
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 been met. Therefore, 
we decided that the Plan has to pay for the acute inpatient psychiatric hospital care provided from March 1, 
2023, through March 14, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.