Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient psychiatric hospital care provided from January 20, 
2023, through February 9, 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 that 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 medically necessary. Our physician reviewer found that 
the enrollee was admitted for acute inpatient psychiatric hospitalization on January 20, 2023 with Autism 
Spectrum Disorder, Schizophrenia Spectrum Disorder, unspecified and Other Psychotic Disorder. Based upon 
the review of the records provided, it was expected that this enrollee would improve in a reasonable period of 
time although he did not have dangerousness to self or others. He did have auditory but no visual 
hallucinations, delusions, and was showing active behavioral issues. It did appear medically necessary and 
reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care  
although he did not have dangerousness to self or others. This enrollee did have perceptual disturbance 
including delusions, and auditory but no visual hallucinations. The health plans denial of inpatient psychiatric 
services appears inappropriate. This enrollee did appear to require inpatient mental health treatment as although 
he was not a danger to himself or others he was having auditory hallucinations and required active treatment. It 
did appear that active treatment was taking place. It did appear that the services were reasonably expected 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 did appear that the records were supervised and evaluated 
by a physician. Based upon the review of the records provided, the enrollee does meet criteria for coverage of 
the acute inpatient mental health treatment provided. 
  
 
 
 
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 been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient psychiatric hospital care provided from January 20, 2023, through February 9, 2023.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.