Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mental health inpatient psychiatric services.
You asked the Plan to pre-approve mental health inpatient psychiatric services. You say that the enrollee has chronic depression and needs inpatient care for treatment and a denial of authorization would delay treatment and the enrollee would have to attempt outpatient treatment, which would be difficult with the lack of community or support he has. The Plan denied your request. The Plan says based on Medicare guidelines, the
mental health inpatient psychiatric services you and/or your provider are requesting do not meet the requirements.
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 mental health inpatient psychiatric services. Our reviewer says that mental health inpatient psychiatric services are not medically necessary. Our physician reviewer found that the enrollee was admitted to the acute inpatient psychiatric hospitalization on August 10, 2021 with Major Depressive Disorder, Single Episode, Moderate Neurocognitive Disorder. Based upon review 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, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. The enrollee was cooperative and compliant with medication. 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, auditory or visual hallucinations or abnormal behaviors. The health Plan's denial of continued inpatient psychiatric services appears appropriate. 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 delusions, auditory or visual hallucinations. 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. It appears that the services were supervised and evaluated by a physician. Based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of August 18, 2021 forward and could have been 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 or aggression being cooperative and compliant while not showing any 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 mental health inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pre-approve mental health inpatient psychiatric services.