Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve the continuation of inpatient mental health care from January 28, 2020 and forward.

You asked the Plan to pre-approve the continuation of inpatient mental health care from January 28, 2020 and forward. You say that the requested continuation of inpatient mental health care is medically necessary. The Plan denied your request. The Plan says that the requested continuation of inpatient mental health care does not meet criteria.

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 pre-approve the continuation of inpatient mental health care from January 28, 2020 and forward. Our reviewer says that the requested continuation of inpatient mental health care is medically necessary. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospital unit on January 21, 2020 with Schizoaffective Disorder Bipolar Type. Based upon review of the records provided it was expected this enrollee would improve in a reasonable period of time beyond the dates in question as although he was not showing any dangerousness to self or others, no auditory or visual hallucinations, he had aggressive behaviors that were difficult to contain. 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 the enrollee remained quite difficult for the staff to manage him and for the enrollee to be functional. The health plan's denial of continued inpatient psychiatric services appears inappropriate.
This enrollee did require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any auditory or visual hallucinations but was showing behavioral issues. It did appear that active treatment was taking place beyond the date in question. It did appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. I am unable to find an individualized treatment plan however the entire record is not present. It appears that the services were supervised and evaluated by a physician. Based upon review of the records provided, this enrollee does meet the criteria for treatment in an acute inpatient mental health unit beyond the date in question of January 28, 2020 and forward as the enrollee cannot be treated in a lesser restrictive setting at this time. Although he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, or delusions, he was showing abnormal behavior where he could not function in a lower treatment setting. 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 continuation of inpatient mental health care from January 28, 2020 and forward have been met. Therefore, we decided that the Plan has to pre-approve the continuation of inpatient mental health care from January 28, 2020 and forward.

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.