Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mental health partial hospitalization services from July 15, 2021, forward.

You asked the Plan to pre-approve mental health partial hospitalization services. You say that this requested service continues to be medically necessary. The Plan denied your request. The Plan says this level of care is no longer medically reasonable and necessary.

The Plan follows Medicare rules. Medicare rules say that mental health partial hospitalization services are subject to the criteria listed in the Medicare rules section. 

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 mental health partial hospitalization services. Our reviewer says that the requested mental health partial hospitalization services are not medically necessary and reasonable from July 15, 2021, forward. Our physician reviewer found This 52-year-old female is requesting reimbursement for partial hospitalization program for treatment of Major Depressive Disorder, Recurrent, Severe without Psychotic Features. Based upon review the records provided this patient was not showing any dangerousness to self or others and not showing any perceptual disturbance or psychosis. This patient was cooperative with care. In cases such as this an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System is indispensable in determining necessary level of care for adults.

In terms of Risk Of Harm, the records support a score of 1 due to a lack of current suicidal ideation and no self-harming behaviors. With regards to Functional Status, the records support a score of 1 due to no problem with impairment. In terms of Medical, Addictive and Psychiatric Comorbidity, the records support a score of 1 due to overall medical stability. In terms of level of stress of the Recovery Environment, the records support a score of 1 due to a stable living situation. With regards to Level Of Support for the recovery environment, the records support a score of 1 due to availability of treatment resources. With regards to Treatment And Recovery History, the records support a score of 1 due to no history of previous success at the partial hospital treatment center level of care. In terms of Engagement And Recovery Status, the records support a score of 1 due to cooperation in treatment and insight into his need for treatment along with insight into her treatment needs. Thus, the patient has a composite score of 7. This correlates with treatment in a community-based outpatient clinic setting. All told, the requested partial hospitalization program services are not medically necessary for the treatment of this patient. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of mental health partial hospitalization services have not been met. Therefore, we decided that the Plan does not have to pre-approve mental health partial hospitalization services from July 15, 2021, forward.