Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric hospital services. 
 
You asked the Plan to pre-approve continued inpatient psychiatric hospital services. You say that the enrollee is 
not safe to discharge because he is requesting to have inpatient electroconvulsive therapy (ECT) treatments. 
The enrollee endorses depression and a passive death wish but has consistently denied suicidal and homicidal 
ideation and psychosis since admission. The Plan denied your request. The Plan says the continued care is not 
medically necessary as of March 21, 2023, as the enrollee is at his new chronic baseline. 
 
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 psychiatric hospital 
services. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
enrollee was admitted to the acute inpatient psychiatric hospitalization on March 16, 2023, with 
Schizoaffective Disorder, Bipolar Type, Schizoaffective Disorder, Depressed Type, PTSD, Heroin Use 
Disorder, Cocaine Use Disorder, Amphetamine Use Disorder and Alcohol Use Disorder. Based upon review, it 
was expected this enrollee would improve in a reasonable period of time beyond the dates in question although 
he was not showing any dangerousness to self or others. He did not have any auditory or visual hallucinations 
and had no aggressive behaviors while or 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 he 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. 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 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 the enrollees 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, this enrollee does not meet 
the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of March 21, 
2023, 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, delusions and was 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 psychiatric hospital services 
 have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient 
psychiatric hospital services.