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 
October 10, 2022, through October 11, 2022. 
 
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 acute inpatient psychiatric hospitalization on October 2, 2023 with 
Schizophrenia, Chronic Paranoid Time with Delusional Thought, Rule out Schizoaffective Disorder, Possible 
Posttraumatic Stress Disorder, and Rule out Major Depressive Disorder. 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. 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 the criteria for coverage of the acute inpatient 
psychiatric hospital care provided from October 10, 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 October 10, 2022, through  
October 11, 2022.