Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient psychiatric services.

You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the enrollee is still in house at this time and that the Plan's denial is not medically appropriate. The Plan denied your request. The Plan says that the enrollee no longer meets the criteria for an inpatient level of care. The Plan says that there are other services that may be available to the enrollee as part of his mental health benefits.

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 inpatient psychiatric hospital services. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on May 29, 2021, with Bipolar Disorder Unspecified, possible Schizophrenia Spectrum Disorder and Vascular Dementia without Behavioral Disturbance. Based upon review 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, he did have auditory and visual hallucinations and aggressive behaviors therefore being an acute threat of safety. The enrollee was uncooperative and not compliant with 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 he did not have any suicidal or homicidal thoughts, he did have auditory and visual hallucinations and abnormal behaviors. 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 although he was not a danger to himself or others this patient did have delusions, auditory and visual hallucinations. 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. It appears that the services were supervised and evaluated by a physician. Based upon review the records provided, this enrollee does meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of June 10, 2021, forward and could not have been treated in a lesser restrictive setting. The enrollee was showing acute 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 inpatient psychiatric hospital services have been met. Therefore, we decided that the Plan has to pre-approve inpatient psychiatric services.

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.