Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient behavioral health admission provided from
May 22, 2021, through May 27, 2021.
You asked the Plan to pay for an inpatient behavioral health admission. The Plan denied your request. The Plan
says the clinical information furnished does not substantiate the need for treatment at the requested level of care
from May 22, 2021 forward and medical necessity was not met. There is no evidence provided that member's
treatment needs cannot be met at a less restrictive, outpatient 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 an inpatient behavioral health admission
provided from May 22, 2021, through May 27, 2021. Our reviewer says that the inpatient behavioral health
services were not medically necessary. Our physician reviewer found that based upon review 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, no auditory or visual hallucinations and no
aggressive behaviors. This enrollee was compliant and cooperative with treatment. 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 aggressive behaviors. The health Plan's denial of continued inpatient psychiatric services
appears appropriate. 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 auditory or visual
hallucinations or behavioral issues. 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 the records provided, this patient does not meet
the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of
May 22, 2021 forward and could have been treated in a lesser restrictive setting as he was not showing any
suicidal or homicidal ideation, auditory or visual hallucinations and was not showing any aggressive behaviors
while being cooperative and compliant.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an inpatient behavioral health admission provided from May 22, 2021, through
May 27, 2021 have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient
behavioral health admission provided from May 22, 2021, through May 27, 2021.