Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient psychiatric hospitalization 
from March 7, 2022 forward. 
 
You asked the Plan to pre-approve continuation of inpatient psychiatric hospitalization from March 7, 2022 
forward. The Plan denied your request. The Plan says Medicare guidelines say that patients in inpatient 
psychiatric care may be discharged by stepping down to a less intensive level of outpatient care. Stepping down 
to a less intensive level of service would be considered when patients no longer require 24-hour observation for 
safety, diagnostic evaluation, or treatment. 
 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 of inpatient psychiatric 
hospitalization from March 7, 2022 forward. Our reviewer says that continuation of inpatient psychiatric 
hospitalization from March 7, 2022 forward 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 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. 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 patients condition or for the purpose of diagnosis. I am 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 patient does not meet 
the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of  
March 7, 2022 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 continuation of inpatient psychiatric hospitalization from March 7, 2022 
forward have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of 
inpatient psychiatric hospitalization from March 7, 2022 forward.