Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve continued inpatient mental health care from January 29, 2020 and forward.
You asked the Plan to pre-approve continued inpatient mental health care from January 29, 2020 and forward. You say that the requested continuation of inpatient mental health care from January 29, 2020 and forward is medically necessary. The Plan denied your request. The Plan says that the requested continuation of inpatient mental health care from January 29, 2020 and forward does not meet criteria.

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 January 29, 2020 and forward. Our reviewer says that the requested continuation of inpatient mental health care from January 29, 2020 and forward is medically necessary. Our physician reviewer found this enrollee was admitted to the acute inpatient psychiatric hospital unit on January 18, 2020 with Schizoaffective Disorder. 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, he was not showing any hallucinations or aggressive behaviors but was showing delusions. 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, no hallucinations or aggressive behaviors but was showing delusions. The health plan's denial of continued inpatient psychiatric services appears inappropriate. This enrollee does 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 auditory or visual hallucinations or behavioral issues. 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 hospital unit beyond the date in question of January 29, 2020 and forward. 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 January 29, 2020 and forward have been met. Therefore, we decided that the Plan has to pre-approve continued inpatient mental health care from January 29, 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.