Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient mental health admission.
You asked the Plan to pre-approve an acute inpatient mental health admission. You say that the admission is medically necessary. The Plan denied your request. The Plan says the documentation received indicates the intensity of treatment (the type of care provided on the treatment unit) and the relative freedom of movement (the ability to move freely on the treatment unit without restriction) afforded to the member is inconsistent with an acute inpatient mental health treatment setting.
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 an acute inpatient mental health admission. Our reviewer says that the acute inpatient mental health admission is not medically necessary. Our physician reviewer found that 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. The enrollee did have auditory no visual hallucinations and no reported aggressive behaviors. He was 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 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. 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 September 7, 2021 forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation. He did have long-standing delusions, auditory no visual hallucinations while not showing any behaviors or aggression. He was cooperative and compliant with treatment 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 an acute inpatient mental health admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient mental health admission.