Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from April 8, 2020 and forward. You asked the Plan to pre-approve the continuation of inpatient mental health care from April 8, 2020 and forward. You say that the continuation of inpatient mental health care from April 8, 2020 and forward is medically necessary. The Plan denied your request. The Plan says the continuation of inpatient mental health care from April 8, 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 the continuation of inpatient mental health care from April 8, 2020 and forward. Our reviewer says that the continuation of inpatient mental health care from April 8, 2020 and forward is not medically necessary. Our physician reviewer found this enrollee was involuntarily admitted to the acute inpatient psychiatric hospital on April 3, 2020 with Psychosis, not otherwise specified, Schizoaffective Disorder, Bipolar Type and Developmental Disability. Based upon review of the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others without aggressive behaviors. 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 he did not have any suicidal or homicidal thoughts, hallucinations or abnormal behaviors. This enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any illusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. I am unable to find an individualized treatment plan however the entire record is not present. It appears that the services were supervised and evaluated by a physician. Based upon review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health setting beyond the date in question of April 8, 2020 and forward and the enrollee could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression and was being cooperative and compliant while not showing any acute 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 the continuation of inpatient mental health care from April 8, 2020 and forward have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from April 8, 2020 and forward.