Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient psychiatric hospital admission and services. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that inpatient psychiatric 
care is medically necessary for this enrollee who is experiencing postpartum depression. The enrollee's family 
is worried for her safety, and care at an inpatient level is necessary to build a safe discharge plan. The Plan 
denied your request. The Plan says that the criteria for continued inpatient psychiatric care are not met. The 
enrollee can be treated in an 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 pre-approve inpatient psychiatric hospital services. 
Our reviewer says that the health plan's denial of inpatient psychiatric services appears inappropriate in this 
case. Our physician reviewer found that the enrollee was admitted to the acute inpatient psychiatric 
hospitalization on November 1, 2021, with Postpartum Depression and attention deficit hyperactivity disorder 
(ADHD). Based upon review the records provided it is expected this enrollee will improve in a reasonable 
period of time as she does not have dangerousness to self or others and was not showing any auditory/visual 
hallucinations or any aggressive behaviors, but she was unable to care for herself and her child with thoughts of 
leaving her child at the police station. It does appear medically necessary and reasonable to have psychiatric 
care provided at the acute inpatient level of care rather than a lower level of care as she was unable to care for 
herself and her child. It does appear that active treatment was taking place. It does appear that the services are 
reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. Our reviewer is unable 
to find an individualized treatment plan, however the entire record is not present. It does 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 criteria for acute inpatient mental health treatment as she is unable to care for herself 
and her child. 
 
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 inpatient psychiatric hospital admission and services.  
 
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.