Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient psychiatric hospitalization level of care.
You asked the Plan to pre-approve acute inpatient psychiatric hospitalization level of care. The Plan denied your request. The Plan says the member was stabilized in an acute psychiatric inpatient facility prior to transfer to state hospital. The member's psychiatric treatment needs can be safely and appropriately met at a lower level of care of care such as outpatient level of care with appropriate community supports.
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 acute inpatient psychiatric hospitalization level of care. Our reviewer says that acute inpatient psychiatric hospitalization is not medically necessary. Our physician reviewer found that this 35-year-old female was admitted to the acute inpatient psychiatric hospitalization on January 24, 2021 with Bipolar Disorder Type I and Borderline Personality Disorder. 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 although she did have suicidal or homicidal ideation noted, the enrollee is future goal oriented of getting married. She has no auditory or visual hallucinations. This enrollee did not show any abnormal behaviors or any symptoms which would require acute treatment. 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 although she did have dangerousness to self or others with no intent or plan, she was compliant with her treatment. The health Plan's denial of continued inpatient psychiatric services is appropriate. This enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others, no auditory hallucinations or visual hallucinations while being cooperative with treatment. 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 enrollee's condition or for the purpose of diagnosis beyond the date in question. I am unable to find an individualized treatment plan however it is alluded to in the record. 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 continued acute inpatient mental health treatment for the dates in question of August 27, 2021 forward as this enrollee had suicidal and homicidal thoughts but no plan and was future goal directed. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. This enrollee was not showing any aggressive behaviors, or any treatment required for acute threats of 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 acute inpatient psychiatric hospitalization level of care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient psychiatric hospitalization level of care provided from August 27, 2021 and forward.