Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve continuation of inpatient mental health care, for the enrollee.
You asked the Plan to pre-approve inpatient mental health care. You say that the enrollee has had several
serious overdose attempts and feel they are at risk for suicide. The Plan denied your request. The Plan says that
the request is not medically necessary because the records show the enrollee has little improvement and need
long term placement.
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 mental health care. Our
physician reviewer found based upon review the records provided it was expected this enrollee would improve
in a reasonable period of time for the dates in question as they although did not have homicidal ideation noted
and denied any visual hallucinations, this enrollee did have suicidal ideation with a plan to overdose and
auditory hallucination. The enrollee was compliant with treatment while 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 they did have dangerousness to
themselves but not others. The enrollee was compliant with her 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 they were a danger to themselves but not others and did
auditory oh visual hallucinations. 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 enrollee's condition or for the
purpose of diagnosis beyond the date in question. Our physician reviewer was unable to find an individualized
treatment plan however the entire chart 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 meet
the criteria for continued acute inpatient mental health treatment for the dates in question of December 14,
2021, forward as this enrollee was shown to be a danger to themselves but not others. The enrollee was not
showing any delusions that have auditory no visual hallucinations. The enrollee was cooperative/compliant
with treatment.
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 mental health care have been met. Therefore, we decided that the Plan
has to pre-approve continuation of inpatient mental health care, for the enrollee.
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.