Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient mental health care provided from December 31, 
2022, to January 20, 2023. 
 
You asked the Plan to pay for the inpatient mental health care. You say that these services were medically 
necessary and are supported in the medical record. The Plan denied your request. The Plan says it has decided 
to pay for the inpatient mental health services from December 20, 2022, to December 30, 2022.  However, the 
Plan argues that care after this date was not medically necessary.  The Plan says that the enrollee could have 
been treated in a less restrictive setting from December 31, 2022, forward. 
 
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 inpatient mental health care. Our 
reviewer says that the inpatient mental health services were not medically necessary on the dates of service in 
question. Our physician reviewer found rhis 82-year-old male was admitted to the acute inpatient psychiatric 
hospitalization on December 20, 2022, with Major Depressive Disorder, Recurrent, Severe with Psychotic 
Symptoms. Based upon review of the records provided it was not expected 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, auditory or visual hallucinations and 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 plan's 
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, 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 for the dates in question were 
reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis. 
Our doctor said they were unable to find an individualized treatment plan, however the entire record is not 
present. It appears that the services were supervised and evaluated by a physician. Based upon review the 
records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health 
treatment beyond the date in question of December 31, 2022, forward and could have been treated in a lesser 
restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, 
delusions and was not showing any behaviors or aggression being cooperative and compliant while not 
showing any acute 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 inpatient mental health care have not been met. Therefore, we decided that 
the Plan does not have to pay for inpatient mental health care provided from December 31, 2022, to January 20, 
2023.