Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve the continuation of inpatient mental health care from July 14, 2020 and forward.You asked the Plan to pre-approve the continuation of inpatient mental health care from July 14, 2020 and forward. You say that the continuation of inpatient mental health care from July 14, 2020 and forward is medically necessary.The Plan denied your request. The Plan says that the continuation of inpatient mental health care from July 14, 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 the continuation of inpatient mental health care from July 14, 2020 and forward. Our reviewer says that the continuation of inpatient mental health care from July 14, 2020 and forward is medically necessary. Our physician reviewer found this enrollee was admitted to the acute inpatient psychiatric hospital on July 11, 2020 with Schizophrenia Undifferentiated Type and Alcohol Use Disorder, Mild. Based upon review of the records provided it was 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, visual hallucinations and without aggressive behaviors although he is disorganized and labile with auditory hallucinations. He was compliant with medication. 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 he did not have any suicidal or homicidal thoughts, visual hallucinations or abnormal behaviors he was disorganized and labile with auditory hallucinations.This enrollee did 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 visual hallucinations but had auditory hallucinations. It did appear that active treatment was taking place beyond the date in question. It did 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. I am unable to find an individualized treatment plan however the entire record is not present. It appears that the services were supervised and evaluated by a physician. Based upon review of the records provided, this enrollee does meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of July 14, 2020 and forward and could not have been treated in a lesser restrictive setting. Although he was not showing any suicidal or homicidal ideation, visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety, he was however, showing auditory hallucinations, disorganization and lability.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continuation of inpatient mental health care from July 14, 2020 and forward have been met.Therefore, we decided that the Plan has to pre-approve the continuation of inpatient mental health care from July 14, 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.