Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health care from April 21, 2020 and forward.You asked the Plan to pre-approve continued inpatient mental health care from April 21, 2020 and forward. You say that the continued inpatient mental health care from April 21, 2020 and forward is medically necessary.The Plan denied your request. The Plan says the continued inpatient mental health care from April 21, 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 mental health care from April 21, 2020 and forward. Our reviewer says that the continued inpatient mental health care from April 21, 2020 and forward is not medically necessary. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospital on April 17, 2020 with Unspecified Psychosis Not Due To Substance or Known Physiologic Condition and History of Dementia. 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 while not showing any acute threats to safety. 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. The enrollee was treated under an individualized treatment plan found in the record. 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 April 21, 2020and 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 while not showing any 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 continued inpatient mental health care from April 21, 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 April 21, 2020 and forward.