Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient psychiatric hospital services provided from  
January 23, 2023, to January 25, 2023.  
 
You asked the Plan to pay for inpatient psychiatric hospital services. You say that the inpatient psychiatric 
hospital services were medically necessary. The Plan denied your request. The Plan says the inpatient 
psychiatric hospital services were 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 inpatient psychiatric hospital services 
provided from January 23, 2023, to January 25, 2023. Our reviewer says that the requested inpatient psychiatric 
hospital services provided from January 23, 2023, to January 25, 2023 are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that based upon review 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. 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 enrollees condition or for the purpose of diagnosis. It appears that the services were supervised 
and evaluated by a physician. Based upon review the records provided, this enrollee does not meet the criteria 
for treatment in an acute inpatient mental health treatment as of January 23, 2023 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 inpatient psychiatric hospital services provided from January 23, 2023, to 
January 25, 2023 have not been met. Therefore, we decided that the Plan does not have to pay for inpatient 
psychiatric hospital services provided from January 23, 2023, to January 25, 2023.