Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve a continued stay at the inpatient behavioral health level of care 
from September 18, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the enrollee has a long 
history of multiple suicide attempts, and you would like additional extended acute mental health treatment days 
to be considered for authorization. The Plan denied your request. The Plan says that a continued stay at the 
inpatient behavioral health level of care for this admission is not medically necessary beginning September 18, 
2023. 
 
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 inpatient psychiatric hospital services. 
Our physician reviewer found that it was expected this enrollee would improve in a reasonable period of time 
beyond the dates in question as the enrollee was showing any dangerousness to self, but not others. The 
enrollee had no auditory or visual hallucinations and without aggressive behaviors. It did 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 the enrollee did have any suicidal no homicidal thoughts. 
The enrollee has no auditory or visual hallucinations or abnormal behaviors. The Health Plans denial of 
continued inpatient psychiatric services appears inappropriate. This enrollee did require inpatient mental health 
treatment beyond the dates in question as noted above as the enrollee was a danger to their self, but not others. 
The enrollee did not have any delusions, auditory or visual hallucinations. It did appear that active treatment 
was taking place beyond the date in question. It did 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. 
This enrollee was treated under an individualized treatment plan found in the record. It appears that the services 
were supervised and evaluated by a physician. Based upon review the records provided, this enrollee does meet 
the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of September 
18, 2023, forward and could not have been treated in a lesser restrictive setting as the enrollee was showing suicidal no homicidal ideation. The enrollee had no auditory or visual hallucinations, delusions and was not 
showing any behaviors or aggression. The enrollee has a history of multiple suicide attempts. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided 
that the Plan has to pre-approve a continued stay at the inpatient behavioral health level of care from September 
18, 2023, forward.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.