Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continued acute inpatient psychiatric hospital care 
provided from February 13, 2023, through February 15, 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 these services. 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 the acute inpatient psychiatric hospitalization on January 29, 2023 with 
Major Neurocognitive Disorder, Unspecified with Behavioral Disturbance, Anxiety and Depression. 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 date 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 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 date 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 date in question as noted 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 enrollee's 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 criteria for coverage of the acute inpatient mental health treatment 
provided beyond the date in question of February 13, 2023 forward and could have been treated in a lesser 
restrictive setting. He was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, or 
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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for the continued acute inpatient psychiatric hospital care provided from February 13, 2023, 
through February 15, 2023.