Appeal type: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan has to pre-approve behavioral health inpatient services for October 1, 2020. We decided that the Plan does not have to pre-approve behavioral health inpatient services for October 2, 2020 to discharge. 

You asked the Plan to pre-approve behavioral health inpatient services for October 1, 2020 through discharge. You say that the stay is necessary. The Plan denied your request. The Plan says the stay is not 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 behavioral health inpatient services. Our physician reviewer found based upon review the records provided it was expected this patient would improve initially in a reasonable period of time as they did have dangerousness to self but not others. This patient does have auditory and paranoid delusions no visual hallucinations but was not showing any behavioral issues. It did appear medically necessary and reasonable initially to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as he did have dangerousness to self but not others. The health plan's denial of inpatient psychiatric services appears initially inappropriate. This enrollee did appear initially to require inpatient mental health treatment as they were not a danger to themselves but not others. It did appear that active treatment was taking place. It did initially appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. Our reviewer was unable to find an individualized treatment plan however the entire record is not present. 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 initially meet the criteria for acute inpatient mental health treatment from October 1, 2020 but does not meet criteria for acute inpatient mental health treatment from October 2, 2020 forward as this patient was not shown to be a danger to themselves or others but was without agitation or aggression.

We decided that the Plan has to pre-approve behavioral health inpatient services for October 1, 2020. 

Therefore, we decided that the Plan has to pre-approve behavioral health inpatient services for October 1, 2020. 

We also decided that the Plan does not have to pre-approve behavioral health inpatient services for October 2, 2020 to discharge.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of behavioral health inpatient services have not been met. Therefore, we decided that the Plan does not have to pre-approve behavioral health inpatient services for October 2, 2020 to discharge.

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.