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 June 26, 2023, through June 27, 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 continued acute inpatient psychiatric 
hospital care provided. 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 June 19, 2023 with Major Depressive Disorder, Recurrent, Severe with Psychotic 
Symptoms. 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 date 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 did not meet the 
criteria for coverage of the acute inpatient psychiatric hospital care provided from June 26, 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 continued acute inpatient psychiatric hospital 
care provided from June 26, 2023, through June 27 2023.