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 
November 1, 2022 through November 30, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plans 
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 the admission criteria indicated describes the severity 
of illness and intensity of service criteria that characterizes a patient appropriate for inpatient psychiatric 
hospitalization. 
 
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 acute inpatient psychiatric hospitalization on December 23, 2021 with 
Bipolar Disorder Unspecified, Vascular Dementia and Delirium. Based upon the review of the records 
provided, it was not expected this enrollee would improve in a reasonable period of time for the dates in 
question as she did not have suicidal or homicidal ideation, auditory, or visual hallucinations. The enrollee was 
compliant with treatment 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 date in question as she did not have dangerousness to 
self or others and was compliant with her 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. This enrollee was treated under an individualized treatment plan found in the 
record. Based upon the review of the records provided, the enrollee did not meet the criteria for coverage of the 
acute inpatient psychiatric hospital care provided from November 1, 2022 forward as this enrollee was not 
shown to be a danger to herself or others and did not have delusions, or auditory and visual hallucinations as 
noted. She was cooperative/compliant with 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 November 1, 2022 through 
November 30, 2022.