Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health care. 
 
You asked the Plan to pre-approve continued inpatient mental health care. You say that continued inpatient 
mental health care is medically necessary because the patient's behaviors are erratic and unpredictable. The 
Plan denied your request. The Plan says continued inpatient mental health care is not medically necessary 
because the patient does not have a plan or intent to harm themselves or others. 
 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 continued inpatient mental health care. 
Our reviewer says that continued inpatient mental health care is not medically necessary. Our physician 
reviewer found this 67-year-old male was admitted to an acute inpatient psychiatric hospital on May 2, 2023, 
with major neurocognitive disorder most likely due to frontotemporal disease with behavioral disturbance. 
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. There is no 
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 May 14, 
2023, 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 continued inpatient mental health care have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient mental health care.