Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of partial hospital behavioral health
services.
You asked the Plan to pre-approve the continuation of partial hospital behavioral health services. You say that
the requested continuation of partial hospital behavioral health services is medically necessary. The Plan denied
your request. The Plan says the enrollee does not meet criteria for the requested continuation of partial hospital
behavioral health 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 the continuation of partial hospital
behavioral health services. Our reviewer says that the enrollee does not meet criteria for the requested
continuation of partial hospital behavioral health services. Our physician reviewer found the enrollee was
admitted to the partial hospitalization program on September 7, 2021, with Schizophrenia Paranoid and
Alcohol Use Disorder, Mild. Based upon review of the records provided for the dates in question, the enrollee
was not showing any dangerousness to self or others tolerating treatment and not showing any perceptual
disturbance or psychosis. He was taking long-acting injectable medication for the treatment of his mental
health illness. In cases such as this an evidence-based, objective, instrument such as the American Association
of Community Psychiatrists Level of Care Utilization System is indispensable in determining necessary level
of care for adults. In terms of Risk of Harm, the records support a score of 1 due to a lack of current suicidal
ideation and no self-harming behaviors. With regards to Functional Status, the records support a score of 1 due
to no problems with comorbidity. In terms of Medical, Addictive and Psychiatric Comorbidity, the records
support a score of 1 due to overall medical stability. In terms of level of stress of the Recovery Environment,
the records support a score of 1 due to a stable living situation. With regards to Level of Support for the
recovery environment, the records support a score of 1 due to availability of treatment resources. With regards
to Treatment and Recovery History, the records support a score of 1 due to recent success at the partial
treatment level of care. In terms of Engagement and Recovery Status, the records support a score of 1 due to
cooperation in treatment and insight into his need for treatment along with insight into his treatment needs.
Thus, the enrollee has a composite score of 7. This correlates with treatment in a community-based outpatient
clinic setting. All told, the requested partial hospitalization program services are not medically necessary for
the treatment of this enrollee's condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the continuation of partial hospital behavioral health services have not been
met. Therefore, we decided that the Plan does not have to pre-approve the continuation of partial hospital
behavioral health services.