Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan does not have to pre-approvecontinuation of inpatient mental health care from July 14, 2020 and forward.You asked the Plan to pre-approvecontinuation of inpatient mental health care. You say that continued inpatient care is medically necessary.The Plan denied your request. The Plansays Medicare coverage criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not apply the correct criteria.Our Medical Director looked at the case file and the reopen request. At issue is coverage for continued inpatient psychiatric hospitalization. The Maximus Physician Reviewer determined that, based upon review of the records provided, the enrollee did meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of July 14, 2020 and forward, and could not have been treated in a lesser restrictive setting. Although he was not showing any suicidal or homicidal ideation, visual hallucinations, or delusions, and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety, he was however, showing auditory hallucinations, disorganization and lability.The Plan requested a reopen stating they had already pre-approved care from July 14, 2020 to July 18, 2020. The Plan states that as of July 19, 2020, the enrollee was not exhibiting any acute symptoms to qualify for further inpatient mental health care, in that the enrollee had no acute signs of danger to himself or others or being unable to care for themselves. Additionally, the Plan notes that there was no active treatment that could have been reasonably expected to improve the enrollee's condition.
The medical records show the enrollee had a long history of schizophrenia, who was admitted to the hospital on July 11, 2020after he was found lying on the sidewalk. On July 19, 2020 it is documented that the enrollee's judgement, insight, memory, concentration, attention, fund of knowledge, and abstract thinking were intact and likely at baseline.The enrollee denied any auditory or visual hallucinations anddenied any urges to hurt himself or others. The enrollee was unhappy about the idea of going to a shelter or residential crisis unit; he wanted to live on the streets. There were no reported delusions, phobias or paranoia. On July 20, 2020, a homeless shelter director was contacted to find placement for the enrollee after discharge. On July 22, 2020, the Case Manager met with the enrollee regarding his discharge. On July 23, 2020, the enrollee'ssister was contacted regarding placement of the enrollee. The Plan is correct in this case. The medical records support the Plan's reasoning that the enrollee was not a danger to himself or others, and did not have ongoing acute symptoms that would qualify him for further active treatment in an inpatient psychiatric hospital that would reasonably be expected to benefit his condition.Medicare coverage criteria were not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of inpatient mental health care have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinuation of inpatient mental health care from July 14, 2020 and forward.