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 
June 3, 2023, through June 7, 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 June 3, 2023, through June 7, 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 May 31, 2023 with Major Depressive Disorder, 
Single Episode, Unspecified or Schizoaffective Disorder. Based upon the review of the records provided, it was 
not expected that this enrollee would improve in a reasonable period of time beyond the dates in question as he 
was not showing any dangerousness to self or others, or auditory and visual hallucinations, and was without 
aggressive behaviors while not showing any acute threats of 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 he did not have any suicidal or homicidal thoughts, auditory or visual 
hallucinations, or abnormal behaviors. The health plans denial of continued inpatient psychiatric services 
appears appropriate. This enrollee did not require inpatient mental health treatment beyond the dates in 
question as noted above as he was not a danger to himself or others and did not have any delusions, or auditory 
and visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It 
did not appear that the services for the dates in question were reasonably expected or medically necessary to 
improve the enrollees 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 not 
meet the criteria for coverage of the acute inpatient mental health treatment provided beyond the date in 
question of June 3, 2023 forward and could 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 not been met. 
Therefore, we decided that the Plan does not have to pay for the acute inpatient psychiatric hospital care 
provided from June 3, 2023, through June 7, 2023.