Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient psychiatric/detoxification hospital care 
provided from March 30, 2023, through April 12, 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/detoxification 
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/detoxification 
hospital care provided from March 30, 2023, through April 12, 2023. Our reviewer says that the acute inpatient 
psychiatric/detoxification hospital care provided was not medically necessary. Our physician reviewer found 
that the enrollee was admitted for acute inpatient psychiatric/detoxification hospitalization on March 24, 2023 
with Alcohol Dependence with Withdrawal, Unspecified, Cocaine Use Disorder, and Severe and Unspecified 
Psychosis. 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, 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/detoxification 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 or abnormal behaviors. The enrollee had auditory and command hallucinations although no 
medication changes were made. The health plans denial of continued inpatient psychiatric/detoxification 
services appears appropriate. This enrollee did not require inpatient mental health treatment/detoxification 
beyond the dates in question as noted above as he was not a danger to himself or others and did not have any 
delusions. The enrollee had auditory and visual hallucinations although no medication changes were made. 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. This enrollee was treated under an individualized treatment 
plan found in the record. It appears that the services were supervised and evaluated by a physician. Based upon 
the review of the records provided, this enrollee did not meet the criteria for coverage of the acute inpatient 
mental health treatment beyond the date in question of March 30, 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the acute inpatient psychiatric/detoxification hospital care provided from March 30, 2023, 
through April 12, 2023.