Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation at a psychiatric inpatient facility. 
 
You asked the Plan to pre-approve continuation at a psychiatric inpatient facility. You say that the enrollee is in 
serious condition, and you are concerned that any more changes will be life threatening. You are appealing 
because you have no other choice. You believe the best path forward for the enrollee is to approve this claim so 
you can address her vital needs at her present setting. The Plan denied your request. The Plan says based on the 
information provided, an ongoing stay at a psychiatric inpatient facility is not considered medically necessary. 
This is because there are no new psychiatric symptoms, and the medical team considers the current symptoms 
to be at their baseline. Alternatively, an initial stay at a skilled nursing facility would be covered. 
 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 continuation at a psychiatric inpatient 
facility. Our reviewer says that the service is not medically necessary. Our physician reviewer found based 
upon review the records provided it was not expected this enrollee would improve in a reasonable period of 
time for the dates in question as she did not have suicidal or homicidal ideation, auditory or visual 
hallucinations. The enrollee was compliant with treatment while not showing any acute threats to 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 she did not have dangerousness to self or 
others and was compliant with her treatment. The health plans denial of continued inpatient psychiatric 
services is appropriate. It did not appear that active treatment was taking place beyond the date in question. It 
did not appear that the services were reasonably expected to improve the enrollees condition or for the purpose 
of diagnosis beyond the date in question. Our physician is unable to find an individualized treatment plan 
however, the entire record is not present. It did appear that the records were supervised and evaluated by a 
physician. Based upon review the records provided for the admission of this enrollee does not meet the criteria 
for November 22, 2022, forward as this enrollee was not shown to be a danger to herself or others, delusions, 
auditory or visual hallucinations noted. She was cooperative/compliant with treatment while not showing any 
threats the safety as she awaited placement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation at a psychiatric inpatient facility have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continuation at a psychiatric inpatient facility.