Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond January 8, 2020.
You asked the Plan to pre-approve the continued inpatient psychiatric care. You say that the enrollee can only be treated at the inpatient level at this time and should be allowed to remain in the facility with coverage. The Plan denied your request. The Plan says the enrollee's condition is non-acute and active treatment is not required. A less intensive level of care would be appropriate.
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 continued inpatient psychiatric care. Our reviewer says that ongoing inpatient care is not considered reasonable and necessary. Our physician reviewer found this 22-year-old female was involuntarily admitted to the acute inpatient psychiatric hospitalization on November 12, 2019 with Borderline Personality Disorder, Unspecified Bipolar Disorder with Anxious Distress, Posttraumatic Stress Disorder and Marijuana Use Disorder. Based upon review 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 patient was compliant with medication. 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. The health plan's denial of continued inpatient psychiatric services is appropriate. 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 as a patient appeared to be at baseline behaviors. 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 patient's condition or for the purpose of diagnosis beyond the date in question. This patient 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 the records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of January 8, 2020 forward as this patient 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. 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 continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond January 8, 2020.