Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health care from February
20, 2020 and forward.
You asked the Plan to pre-approve continued inpatient mental health care from February 20, 2020 and forward.
You say that the requested continuation of inpatient mental health care from February 20, 2020 and forward is
medically necessary. The Plan denied your request. The Plan says the requested continuation of inpatient
mental health care from February 20, 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 February 20, 2020 and forward. Our reviewer says that the requested continuation of inpatient mental
health care from February 20, 2020 and forward is not medically necessary. Our physician reviewer found the
enrollee was admitted to the acute inpatient psychiatric hospital on December 16, 2019 with Major Depressive
Disorder Recurrent, Severe with Psychotic Symptoms. 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 abnormal behaviors. 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. I am unable to find an individualized treatment plan however
the entire chart is not present. 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 February 20, 2020 and 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 abnormal behaviors.
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 February 20, 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 February 20, 2020 and forward.