Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care from January 17,
2020 and forward.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that the requested continuation
of inpatient psychiatric care from January 17, 2020 and forward is medically necessary. The Plan denied your
request. The Plan says the requested continuation of inpatient psychiatric care from January 17, 2020 and
forward is 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 pre-approve continued inpatient psychiatric care.
Our reviewer says that the requested continuation of inpatient psychiatric care from January 17, 2020 and
forward is not medically necessary. Our physician reviewer found this enrollee was admitted to acute inpatient
psychiatric hospitalization on December 19, 2019 with Bipolar Disorder, Current Episode Mixed, Severe with
Psychotic Features. Based upon review of the records provided it was not expected this enrollee would improve
in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted
and denied any auditory or visual hallucinations. The enrollee was compliant with treatment. 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 but
was compliant with her treatment. 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 any auditory or visual
hallucinations while being cooperative with treatment. 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
enrollee's condition or for the purpose of diagnosis beyond the date in question. I am unable to find an
individualized treatment plan however the entire chart is not present. It did appear that the records were
supervised and evaluated by a physician.
Based upon review of the records provided, the enrollee does not meet the criteria for continued acute inpatient
mental health treatment for the dates in question of January 17, 2020 forward as this enrollee was not shown to
be a danger to herself or others. She was not showing any auditory or visual hallucinations and was
cooperative/compliant with 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 continued inpatient psychiatric care have not been met. Therefore, we decided
that the Plan does not have to pre-approve continued inpatient psychiatric care from January 17, 2020 and
forward.