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 
February 14, 2023, through February 27, 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 from February 14, 2023, through February 27, 2023 was not 
medically necessary. Our physician reviewer found that the enrollee was admitted for acute inpatient 
psychiatric hospitalization on February 5, 2023 with Major Depressive Disorder with suicidal ideation. 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 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 dates 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. It did appear that the records were supervised and evaluated by a physician. 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 February 14, 2023 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. The enrollee 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 February 14, 2023, through  
February 27, 2023.