Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care from June 26, 2020 and forward.You asked the Plan to pre-approve inpatient mental health care from June 26, 2020 and forward. You say that the inpatient mental health care from June 26, 2020 and forward is medically necessary.The Plan denied your request. The Plan says the inpatient mental health care from June 26, 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 inpatient mental health care from June 26, 2020 and forward. Our reviewer says that the inpatient mental health care from June 26, 2020 and forward is not medically necessary. Our physician reviewer found this enrollee was admitted to the acute inpatient psychiatric hospital on June 18, 2020 with Unspecified Psychosis Disorder, Major Depressive Disorder, Recurrent, Severe with Psychotic Features and Vascular Dementia with Behavioral Disturbance. Based upon review of the records provided, as of June 26, 2020, 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. The enrollee was described as being cheerful, cooperative and interactive. 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, this enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of June 26, 2020 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 to 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 inpatient mental health care from June 26, 2020 and forward have not been met.Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care from June 26, 2020 and forward.