Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pre-approve the continuation of inpatient psychiatric care from December 28, 2021, forward.  You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that inpatient psychiatric care continues to be medically necessary. The Plan denied your request. The Plan says that the criteria for coverage have not been met for these requested services.  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 inpatient psychiatric hospital services. Our reviewer says that the requested inpatient psychiatric care continues to be medically necessary after December 28, 2021. Our physician reviewer found that this 48-year-old female was admitted to the acute inpatient psychiatric hospitalization on December 7, 2021, with Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms. Based upon review of the records provided it was expected this enrollee would improve in a reasonable period of time for the dates in question as although 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 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 although she did not have dangerousness to self or others but was compliant with her treatment, this patient remained anxious and under active treatment. The health plan's denial of continued inpatient psychiatric services is inappropriate. This enrollee did appear to require inpatient mental health treatment beyond the date in question as although she was not a danger to herself or others and did not have any auditory or visual hallucinations while being cooperative with treatment, the patient was continued under active treatment. It did appear that active treatment was taking place beyond the date in question. It did appear that the services were reasonably expected to improve the patient'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 patient does meet the criteria for December 28, 2021, forward.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided that the Plan has to pre-approve the continuation of inpatient psychiatric care from December 28, 2021, forward.   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.