Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient psychiatric hospital care provided from  
November 22, 2022, through December 2, 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 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 the acute inpatient psychiatric hospital care 
provided from November 22, 2022 through December 2, 2022. 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 November 7, 2022 with Schizoaffective Disorder, 
Bipolar Type, and Unspecified Psychosis not due to substance or a known physiologic condition. Based upon 
the review of the records provided, it was expected that this enrollee would improve in a reasonable period of 
time for the dates in question although she did not have suicidal or homicidal ideation, or visual hallucinations. 
The enrollee was compliant with treatment while not showing any acute threats to safety. This enrollee was 
undergoing active treatment.  
  
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 beyond the dates in question as although she did not have 
dangerousness to self or others, she was undergoing active treatment while being compliant with her treatment. 
The health plan's denial of continued inpatient psychiatric services is inappropriate. This enrollee did appear to 
require inpatient mental health treatment beyond the date in question as although she was not a danger to 
herself or others, she did have auditory but no visual hallucinations and was undergoing active treatment. It 
appears that active treatment was taking place beyond the date in question. It did appear that the services were 
reasonably expected to improve the enrollee's 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 does meet the criteria for coverage of the acute inpatient psychiatric hospital care provided from 
November 22, 2022 forward as although she was not shown to be a danger to herself or others, she did have 
delusions, and auditory but no visual hallucinations as noted. She was undergoing active treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the acute inpatient psychiatric hospital care provided have been met. Therefore, 
we decided that the Plan has to pay for the acute inpatient psychiatric hospital care provided from  
November 22, 2022, through December 2, 2022.  
 
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.