Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health care from July 6, 2020
and forward.
You asked the Plan to pre-approve continued inpatient mental health care from July 6, 2020 and forward. You
say that the continued inpatient mental health care from July 6, 2020 and forward is medically necessary. The
Plan denied your request. The Plan says the continued inpatient mental health care 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 mental health care
from July 6, 2020 and forward. Our reviewer says that the continued inpatient mental health care is not
medically necessary. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric
hospital on June 28, 2020 with Schizoaffective Disorder Depressed Type. Based upon review of the records
provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in
question as he was not showing any dangerousness to self or others, no auditory or visual hallucinations and no
aggressive behaviors. This enrollee was compliant with medications and treatment with no perceptual
abnormalities. 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 he did not have
any suicidal or homicidal thoughts, delusions or hallucinations or aggressive behaviors.
This enrollee did not 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 or behavioral
issues. It did not appear that active treatment was taking place beyond the date in question. It did not 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. This enrollee was treated under an individualized treatment
plan found in the record. It appears that the services were supervised and evaluated by a physician. Based upon
review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient
mental health unit beyond the date in question of July 6, 2020 and forward, as the enrollee can be treated in a
lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual
hallucinations, delusions and was not showing any behaviors being cooperative and compliant.
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 mental health care from July 6, 2020 and forward have not
been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health
care from July 6, 2020 and forward.