Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient psychiatric hospital care provided from March 10, 
2023, through March 16, 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 these services. Our reviewer says that the 
acute inpatient psychiatric hospital care provided was medically necessary. Our physician reviewer found that 
the enrollee was admitted for an acute inpatient psychiatric hospitalization on March 10, 2023 with 
Schizoaffective Disorder, Bipolar Type. Based upon the review of the records provided, it was expected that 
this enrollee would improve in a reasonable period of time although he did not have dangerousness to self or 
others, auditory or visual hallucinations, or delusions, the enrollee was showing manic behavior. 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 although he did not have dangerousness to self or others, perceptual disturbance 
including delusions, or auditory and visual hallucinations. The health plans denial of inpatient psychiatric 
services appears inappropriate. This enrollee did appear to require inpatient mental health treatment although 
he was not a danger to himself or others and was cooperative and compliant, the enrollee was showing 
grandiose behavior and paranoia. It did appear that active treatment was taking place. It did appear that the 
services were reasonably expected to improve the enrollees condition or were for the purpose of a diagnosis. It 
did appear that the records were supervised and evaluated by a physician. Based upon the review of the records 
provided, the enrollee does meet the criteria for coverage of the acute inpatient mental health treatment 
provided although he was not shown to be a danger to himself or others and did not have auditory or visual 
hallucinations. He was prescribed medication and was showing manic behavior with liability. 
 
  
 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient psychiatric hospital care provided from March 10, 2023, through March 16, 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.