Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for a continued psychiatric inpatient admission provided from May 21, 2021, through May 25, 2021.  You asked the Plan to pay for a continued psychiatric inpatient admission. The Plan denied your request. The Plan says this member no longer met criteria for continued psychiatric inpatient level of care, and any further clinical concerns could have been addressed at a lower 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 pay for a continued psychiatric inpatient admission. Our reviewer says that a continued psychiatric inpatient admission is not medically necessary. Our physician reviewer found that the enrollee was admitted to the acute inpatient psychiatric hospitalization on May 13, 2021 with Schizoaffective Disorder Bipolar Type. 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. The notes state that the enrollee did have auditory no visual hallucinations, however no medication changes were made, and no symptoms of the hallucinations are documented. The enrollee 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. 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. Documentation showed auditory no visual hallucinations however there is no symptoms in the record and the enrollee was cooperative with treatment as she awaited placement. 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 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 enrollee does not meet the criteria for May 21, 2021 forward as she was not shown to be a danger to herself or others. She was apparently showing auditory hallucinations however this is not found in the subjective section. She was not showing any visual hallucinations. She was cooperative/compliant with treatment while not showing any threats the safety as she awaited placement.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a continued psychiatric inpatient admission have not been met. Therefore, we decided that the Plan does not have to pay for a continued psychiatric inpatient admission provided from  May 21, 2021, through May 25, 2021.