Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve the continuation of inpatient mental health care from October 27, 
2020 and forward. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the continuation of 
inpatient mental health care from October 27, 2020 and forward is medically necessary. The Plan denied your 
request. The Plan says that the continuation of inpatient mental health care from October 27, 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 inpatient psychiatric hospital services. 
Our reviewer says that the continuation of inpatient mental health care from October 27, 2020 and forward is 
medically necessary. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric 
hospital on October 9, 2020 with Schizoaffective Disorder Unspecified Type. Based upon review of the records 
provided it was 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 but had auditory and visual hallucinations. It did 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 although she did not have dangerousness to self or 
others this enrollee was quite delusional. This enrollee did appear to require inpatient mental health treatment 
beyond the date in question as although she was not a danger to herself or others she did have auditory 
hallucinations and visual hallucinations. It did appear that active treatment was taking place beyond the date in 
question. It did appear that the services were reasonably expected to improve the enrollee's condition or for the 
purpose of diagnosis beyond the date in question. This enrollee was treated under an individualized treatment 
plan alluded to in the record. It did appear that the records were supervised and evaluated by a physician. Based 
upon review of the records provided for this enrollee, the enrollee does meet the criteria for continued acute 
inpatient mental health treatment for the dates in question of October 27, 2020 and forward as this enrollee is 
not shown to be a danger to herself or others, but is showing both auditory and visual hallucinations while 
requiring help with activities of daily living. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve the continuation of inpatient mental health care from October 27, 2020 and 
forward.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.