Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to approve continued inpatient psychiatric care beyond October 21, 2020.

You asked the Plan to approve the continued inpatient psychiatric care. You say that the records provided support the need for continued inpatient psychiatric care. The Plan denied your request. The Plan says the requested inpatient psych care is not medically necessary because the records show that the enrollee's condition has improved and that she is no longer a threat to herself or others.

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 approve the continued inpatient psychiatric care. Our reviewer says that the records do not support that ongoing care is medically reasonable and necessary. Our physician reviewer found this 72-year-old female was admitted to the acute inpatient psychiatric hospitalization on October 15, 2020 with Major Depressive Disorder, Recurrent, Severe with Psychotic Features, Generalized Anxiety Disorder and Cluster B Personality 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 treatment while not showing any acute threats to safety. It did not appear 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 approve the continued inpatient psychiatric care. Our reviewer says that the records do not support that ongoing care is medically reasonable and necessary. Our physician reviewer found this 72-year-old female was admitted to the acute inpatient psychiatric hospitalization on October 15, 2020 with Major Depressive Disorder, Recurrent, Severe with Psychotic Features, Generalized Anxiety Disorder and Cluster B Personality 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 treatment while not showing any acute threats to safety. 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.

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 approve continued inpatient psychiatric care beyond October 21, 2020.