Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve continuation of inpatient psychiatric care provided from 
December 2, 2022, to December 9, 2022. 
 
You asked the Plan to pre-approve continuation of inpatient psychiatric care. You say that continuation of 
inpatient psychiatric care was medically necessary. The Plan denied your request. The Plan says that 
continuation of inpatient psychiatric care after the last covered day of December 1, 2022 was not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
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 
care. Our reviewer says that the requested continuation of inpatient psychiatric care is considered medically 
reasonable and necessary in this case. Our physician reviewer found that based upon review the records 
provided, it was expected this enrollee would improve in a reasonable period of time beyond the dates in 
question as although the enrollee was not showing any dangerousness to self or others, auditory or visual 
hallucinations but was undergoing active treatment. 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 although he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations he 
was undergoing active treated. 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 although he was not a danger to himself or others did have delusions and paranoia. 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 enrollees 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 meet the criteria for treatment in an acute inpatient mental 
health treatment beyond the date in question forward and could not have been treated in a lesser restrictive 
setting as although he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, he 
was showing delusions and required active treatment. 
                                                                                                                              
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 care have been met. Therefore, we decided 
that the Plan has to pre-approve continuation of inpatient psychiatric care provided from December 2, 2022, to 
December 9, 2022.  
 
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.