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 
March 1, 2023, through April 1, 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 March 1, 2023, through April 1, 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 October 17, 2022 with Schizophrenia Spectrum 
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, auditory or visual hallucinations, and was without aggressive behaviors 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 dates in question as the enrollee 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 beyond the date in question of March 1, 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 March 1, 2023, through April 1, 2023.