Appeal type: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan has to pre-approve ECT treatment. We decided that the Plan does not have to pre-approve continued inpatient mental health care from August 24, 2021 and forward.

You asked the Plan to pre-approve continued inpatient mental health care from August 24, 2021 and forward and ECT treatment. You say that the requested continued inpatient mental health care from August 24, 2021 and forward and ECT treatment are medically necessary. The Plan says that the requested continued inpatient mental health care from August 24, 2021 and forward and ECT treatment are not medically necessary.

We decided that the Plan has to pre-approve ECT treatment.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.

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 ECT treatment. Our reviewer says that the requested ECT treatment is medically necessary. Our physician reviewer found the requested ECT treatment is medically necessary for the enrollee in this case; however, the ECT treatment can safely be provided on an outpatient basis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ECT treatment have been met. Therefore, we decided that the Plan has to pre-approve ECT treatment.

We also decided that the Plan does not have to pre-approve continued inpatient mental health care from August 24, 2021 and forward.

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 August 24, 2021 and forward. Our reviewer says that the requested continued inpatient mental health care from August 24, 2021 and forward is not medically necessary. Our physician reviewer found 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 August 24, 2021 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 threats the 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 August 24, 2021 and forward have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health care from August 24, 2021 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.