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 
April 12, 2023, through April 14, 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 April 12, 2023, through April 14, 2023. Our reviewer says that the acute inpatient psychiatric 
hospital care provided was not medically necessary. Our physician reviewer found that the enrollee was 
involuntarily admitted for acute inpatient psychiatric hospitalization on April 5, 2023 with Major Depressive 
Disorder, Recurrent, Severe with Psychotic Symptoms. Based upon the review of the records provided, it was 
not expected that this enrollee would improve in a reasonable period of time for the dates in question as she did 
not have suicidal or homicidal ideation, or auditory and visual hallucinations. The enrollee was cooperative but 
not attending treatment and 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 she did not have dangerousness to self or others but was cooperative and was 
not attending treatment. The health plans denial of continued inpatient psychiatric services is appropriate. This 
enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a 
danger to herself or others and did not have 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 were reasonably 
expected to improve the enrollees condition or were for the purpose of a diagnosis beyond the date in question. 
It did appear that the records were supervised and evaluated by a physician. Based upon the review of the 
records provided the enrollee does not meet criteria for coverage of the acute inpatient psychiatric hospital care 
from April 12, 2023 forward as this enrollee was not shown to be a danger to herself or others, and did not have 
auditory or visual hallucinations as noted. She was cooperative but not attending treatment while not showing 
any 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 acute inpatient psychiatric hospital care provided from April 12, 2023, through April 14, 
2023.