Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the member is still
inpatient at the facility, and you are currently trying to find placement at an assisted living facility. The Plan
denied your request. The Plan says the member does not continue to meet medical necessity criteria for
inpatient psychiatric care. The member can be managed at a lower 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 inpatient psychiatric hospital services are not medically necessary. Our physician
reviewer found that based upon review of 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, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats
of safety. The enrollee was cooperative and compliant with medication. 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 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 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 enrollee's condition or for the purpose of diagnosis. 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 December 13, 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, 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 inpatient psychiatric hospital services have not been met. Therefore, we decided
that the Plan does not have to pre-approve inpatient psychiatric hospital services.