Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient behavioral stay. 
 
 
 
 
 You asked the Plan to pre-approve continued inpatient behavioral stay. You say that you are not ready to be 
discharged and need more time. You also say you need help and do not feel okay going home with the thoughts 
you are still having. The Plan denied your request. The Plan says it does 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 last covered day as you did not have dangerousness to self or others and have been compliant with 
treatment. 
 
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 continued inpatient behavioral stay. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found based upon review of 
the records provided, it was not expected that you would improve in a reasonable period of time beyond the 
dates in question as you were not showing any dangerousness to self or others, auditory or visual hallucinations 
and without aggressive behaviors while not showing any acute threats of 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 you did not have any suicidal or homicidal thoughts, 
auditory or visual hallucinations or abnormal behaviors. The health plans denial of continued inpatient 
psychiatric services appears appropriate. You did not require inpatient mental health treatment beyond the dates 
in question as noted above as you were not a danger to yourself or others and did not have any delusions, 
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 your condition or for the purpose of diagnosis. The reviewer is 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 the records provided, you do not meet the criteria 
for treatment in an acute inpatient mental health treatment beyond the date in question of April 19, 2023, 
forward and could have been treated in a lesser restrictive setting as you were not showing any suicidal or 
homicidal ideation, auditory or visual hallucinations, delusions and were not showing any behaviors or 
aggression 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 continued inpatient behavioral stay have not been met. Therefore, we decided 
that the Plan does not have to pre-approve continued inpatient behavioral stay.