Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the inpatient psychiatric care provided from April 6, 
2020, to April 8, 2020. 
 
You asked the Plan to pre-approve the inpatient services. You say that you believe that this was necessary care. 
The Plan denied your request. The Plan says no prior authorization was requested for these services and they 
are 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 inpatient services. Our reviewer 
says that the inpatient psychiatric care provided was not shown to be medically reasonable and necessary. Our 
physician reviewer found this 57-year-old male was admitted to the acute inpatient psychiatric/detoxification 
hospitalization on April 6, 2020 with Bipolar Disorder Type I Most Recent Episode Depressed without 
Psychosis, Substance Abuse includes Alcohol Use Disorder, Severe, Cocaine Use Disorder, Severe and 
Generalized Anxiety Disorder. Based upon review the records provided it was not expected this enrollee would 
improve in a reasonable period of time as he did not have dangerousness to self or others, auditory or visual 
hallucinations, delusions and was not showing any behavioral issues. His vitals on admission showed a blood 
pressure 138/78, pulse 56, respirations 20 and temperature 97.3. 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 
as he did not have dangerousness to self or others, perceptual disturbance including auditory or visual 
hallucinations. The health plan's denial of inpatient psychiatric services appears appropriate. This enrollee did 
not appear to require inpatient mental health treatment as he was not a danger to himself or others and was 
cooperative and compliant. It did not appear that active treatment was taking place. It did not appear that the 
services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. 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 acute inpatient mental health treatment as this patient was not shown 
to be a danger to himself or others but was without agitation or aggression without perceptual disturbance 
including auditory or visual hallucinations. The patient was not showing any acute withdrawal symptoms. 
 
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 inpatient services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the inpatient psychiatric care provided from April 6, 2020, to April 8, 2020.