Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient psychiatric services from January 21, 2021, through January 27, 2021.
You asked the Plan to pre-approve continuation of inpatient psychiatric services. The Plan denied your request. The Plan says the clinical information provided does not substantiate the need for treatment at the requested level of care from January 21, 2021 forward. No evidence has been provided that the member's treatment needs cannot be met at a less restrictive, outpatient level of care.
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 continuation of inpatient psychiatric services. Our reviewer says that continuation of inpatient psychiatric services is not medically necessary. Our physician reviewer found that the enrollee is a 61-year-old female who was involuntarily admitted to the acute inpatient psychiatric hospitalization on January 7, 2021 with Bipolar Disorder, Unspecified. Based upon review of 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 no auditory or visual hallucinations. The enrollee did not show any abnormal behaviors or any symptoms which would require acute treatment. She was described as having an improved disorganized thought process. 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, no auditory hallucinations 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 it is alluded to 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 enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of January 21, 2021 forward as the 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. The enrollee was not showing any aggressive behaviors, or any treatment required for acute threats of 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 continuation of inpatient psychiatric services. have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient psychiatric services from
January 21, 2021, through January 27, 2021.