Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial hospitalization services. 
 
You asked the Plan to pre-approve partial hospitalization. You say that partial hospitalization program 
participation is medically necessary for this enrollee. The Plan denied your request. The Plan says the requested 
partial hospitalization services are not medically necessary. The enrollee can be treated at a lower level of care. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 partial hospitalization. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee received partial hospitalization services on November 8, 2021 and is 
requesting continuation of these services for Obsessive-Compulsive Disorder, Major Depressive Disorder, 
Recurrent Episode, Severe, Borderline Personality Disorder and Generalized Anxiety Disorder. Based upon 
review the records provided for the dates in question, the enrollee was not showing any dangerousness to self 
or others, was tolerating treatment and was not showing any perceptual disturbance or psychosis. The 
psychiatric evaluation performed on November 9, 2021, showed the enrollee have no obsessive-compulsive 
thoughts.  
 
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 her need for treatment along with insight into her 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 enrollees 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 partial hospitalization have not been met. Therefore, we decided that the Plan 
does not have to pre-approve partial hospitalization services.